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http://www.archive.org/details/systemofgynaecolOObeeb 


A  SYSTEM  OF 


GYNECOLOGY 


WITB  THREE  HUNDRED   AND  FIFTY-NINE  ILLUSTRATIONS; 

BASED  UPON  A  TRANSLATION  FROM  THE  FRENCH 

OF  SAMUEL  POZZI 


EEVISED    BT 

CURTIS  M.  BEEBE,  M.  D. 

CHICAGO,  ILL. 


1894 

J.  B.  FLINT  &  COMPANY 

NEW  YORK 


COPTBIGHT, 

1892, 
J.  BENTON  FLINT. 


THE  MBRSHON  COMPANY  PRESS, 
SAHWAY,  K.  J. 


PREFACE. 


This  ■work  is  the  result  of  many  years  of  practical  experience  as 
chief  of  the  hospital  service  at  Louraine,  which  is  devoted  especially 
to  the  diseases  of  women.  The  materials  for  the  works  published  by 
Huguier,  Bernutz,  and  Goupil,  Alph.  Guerin,  De  Martineau,  and  others 
were  gathered  from  the  same  field.  Thanks  to  the  increased  facilities 
offered  in  gynecological  surgery  by  the  addition  of  the  Pascal  Annex, 
I  have  for  six  years  been  able  to  give  regular  gynecological  instruc- 
tion, and  the  kindness  of  the  Dean,  M.  Brouardel,  has  permitted  me  to 
conduct  a  supplemental  course  of  gynecology  at  the  Faculty  de  Medi- 
cine. These  lectures  have  served  as  an  outline  in  the  compilation  of 
this  book.  I  have  also,  in  the  course  of  several  journeys  abroad, 
studied  the  methods  of  the  principal  gynecologists  of  England,  Ger- 
many, and  Austria,  and  compared  their  instructions  with  those  of  the 
Faculte  of  Paris,  where  my  own  studies  were  pursued. 

It  is  impossible  to  ignore  the  great  prominence  which  gynecology 
has  assumed.  The  origin  of  its  rapid  progress  it  is  easy  to  trace.  By 
the  introduction  of  antisepsis,  a  new  era  was  opened  to  gynecology  as 
well  as  to  general  surgery.  Active  intervention  has  become  almost 
free  from  danger  in  many  diseases  which  used  to  be  abandoned  to  pal- 
liative or  to  disguised  expectant  treatment.  Thanks  to  antisepsis,  new 
operations  have  been  invented,  and  old  ones  improved  and  restored  to 
favor.  Some  of  the  latter  have  been  boldly  conceived,  and  brilliantly 
performed  by  the  early  teachers,  but  the  great  mortality  due  to  sur- 
gical uncleanliness  caused  their  abandonment.  Such  was  the  case 
with  ovariotomy,  vaginal  hysterectomy,  curetting,  and  even  shortening 
tlie  round  ligaments  ;   their  present  use  is  but  a  revival. 

Previous  to  Pasteur's  great  discovery,  rendered  fruitful  by  Lister, 
boldness  in  operative  medicine  was  sheer  temerity.  If  an  occasional 
success  raised  hope  it  was  at  once  destroyed  by  a  series  of  mishaps. 
In  1822  Sauter  made  the  first  successful  vaginal  hysterectomy  for  the 
cure  of  cancer.     After  this  one  isolated  cure,  eleven  deaths  followed 


'  ^  Preface. 

tlie  first  eleven  operations  performed  in  imitation  of  his,  and  in  all 
probability  a  complete  list  of  the  victims  is  not  known.  Less  than 
twenty  years  ago,  surgery  had  fallen  into  discouragement  and  had  re- 
nounced all  active  measui'es  in  a  greater  portion  of  the  gynecological 
field.  Accidents  during  labor,  or  the  consequences  of  labor,  were  left 
in  the  hands  of  accoucheurs,  and  the  numerous  forms  of  metritis, 
nearly  all  displacements,  and  reflex  nervous  disorders,  perimetritic  in- 
flammations, etc.,  to  the  general  practitioner.  Thus  dismembered  and 
parceled  out  among  surgeons,  general  physicians,  and  obstetricians, 
gynecology  was  far  from  fomiing  the  definite  and  distinct  branch  of 
the  healing  art  that  it  does  at  the  present  day.  Not  so  very  long  ago 
a  good  operator  was  a  good  surgeon,  the  two  terms  being  almost  syn- 
onymous. Tliis  is  no  longer  the  condition.  It  has  become  of  even 
greater  importance  to  avoid  infection  of  the  wound  than  to  perform 
a  brilliant  operation. 

Now  antisepsis  has  triumphantly  overcome  all  opposition  ;  all  our 
instructors  teach  it,  and  the  younger  generation  practice  it  with  in- 
spired fervor.  We  are  as  well  armed  for  the  strife  as  our  neighbors. 
Let  us  profit  by  their  experience,  and  avoid  the  operative  excesses 
into  which  some  have  too  often  fallen. 

In  view  of  these  tendencies,  which,  it  is  to  be  feared,  have  some- 
times caused  the  sacrifice  of  a  careful  clinical  study  of  the  disease,  and 
a  close  and  exact  determination  of  the  diagnosis  and  prognosis  to  the 
exaltation  of  immediate  results,  it  seems  to  me  that  a  definite  role 
falls  naturally  to  the  lot  of  French  gynecology.  Let  it  accept  with- 
out qualification  the  bold  and  useful  inventions  of  foreign  origin,  but 
let  it  exercise  a  more  solicitous  surveillance  over  what  is  in  reality  the 
highest  part  of  our  art,  an  exact  interpretation  of  indications.  There 
will  then  be  no  missing  link  in  the  chain  of  its  records,  and  its  future 
will  be  worthy  of  its  glorious  past. 

My  endeavor  has  been,  as  far  as  possible,  to  present  an  exact  state- 
ment of  the  present  condition  of  science  in  all  countries,  without  giv- 
ing a  cumbersome  mass  of  detail.  For  that  reason  I  have  abstained 
from  dwelling  at  ^w^  length  upon  historical  data  preceding  the  anti- 
septic period,  although  I  have  not  neglected  any  occasion  to  assert 
any  just  claims  of  priority  on  the  part  of  operators,  without  regard 
to  nationality. 

In  a  book  of  instruction  the  autlior  is  often  either  in  danger  of  sac- 
rificing everything   to  perspicuity,   dwelling  upon   the  outlines   and 


Preface.  v 

leaving  in  the  shade  many  details  which  might  interfere  with  the 
clearness  of  his  sketch,  in  which  case  he  is  liable  to  be  incomplete  and 
often  artificial  ;  or  else  he  tries  to  omit  nothing  from  his  picture,  even 
though  the  addition  of  details  and  matter  of  secondary  importance 
takes  something  from  the  prominence  of  the  chief  topics  ;  he  runs  the 
risk,  in  the  latter  case,  of  being  heavy  and  diffuse. 

I  have  constantly  endeavored  to  steer  clear  of  both  dangers,  and 
although  I  may  not  have  attained  entire  success,  yet  I  can  claim  to  have 
done  my  best.  I  deemed  it  essential  to  dwell  at  length  upon  the  more 
recent  gynecological  operations,  which  were  often  incompletely  re- 
ported by  my  predecessors,  and  somewhat  obscurely  described  in  the 
many  existing  works.  On  the  other  hand,  it  seemed  unnecessary  to 
give  a  detailed  anatomical  description  of  the  female  genital  organs  ; 
I  contented  myself  with  a  few  indispensable  general  indications  quite 
sufficient  for  a  work  on  pathology.  The  only  details  entered  into  are 
in  reference  to  the  external  organs  of  generation,  where  certain 
views  had  to  be  stated,  in  regard  to  their  development  and  homology, 
which  seemed  to  me  to  throw  light  upon  the  origin  of  some  interest- 
ing malformations. 

Many  of  the  illustrations  are  original  ;  they  were  drawn  under  my 
direction  by  M.  Nicolet,  who  is  both  skillful  and  intelligent.  I  have 
also  borrowed  from  various  treatises  and  monographs. 


CONTENTS. 


CHAPTER  PAGE 

I.    Antisepsis  in  G-ynecology, 17 

II.    Anesthesia  in  Gynecology, 31 

III.  Means  of  Reunion  and  Hemostasis 34 

IV.  Gynecological  Examinations, 58 

V.    Metritis.— Pathological  Anatomy.— Etiology,        .  77 

VI.  Symptoms,  Progress,  and  Diagnosis  of  the  Me- 
tritis,         103 

VII.    Treatment  of  the  Metritis, 113 

VIII.    Fibroid    Tumors     of    the    Uterus. — Pathological 

Anatomy, 131 

IX.  Fibroid  Tumors  of  the  Uterus.  Symptoms,  Diag- 
nosis, JStiology, 142 

X.  Medical  Treatment  of  Fibroid  Tumors. — Surgical 
Treatment  op  Fibroid  Tumors  op  Vaginal  Evo- 
lution,        153 

XI.    Treatment  op  Fibroid  Tumors  op  Abdominal  Evolu- 
tion.— Myomectomy  and  Hysterectomy,        .        .  170 
XII.    Castration  of  Fibroid  Tumors,         ....  200 

XIII.  Fibroid  Tumors  Complicating  Pregnancy,          .        .  205 

XIV.  Cancer  op  the  Cervix  Uteri.— Pathological  Anat- 

omy, Symptoms,  Diagnosis,  jEtiology,       .        .  209 

XV.    Treatment  op  Cancer  op  the  Cervix,         .        .        .  323 

XVI.    Cancer  of  the  Corpus  Uteri, 244 

XVII.    Displacements  of  the  Uterus. — General  Considera- 
tions.— Anteversions. — Anteflexion,     .        .        .  258 

XVIII.    Posterior  Displacements, 371 

XIX.    Prolapsus  of  the  Genital  Organs,      ....  299 

XX.    Inversion  op  the  Uterus, 325 

XXI.    Deformities  of  the'  Cervix  Uteri,        ....  333 

XXII.    Precocious  and  Late  Menstruation,        ...  345 

XXIII.  Amenorrhcea .        .  346 

XXIV.  Menorrhagia, 350 

XXV.    Dysmenorrhea  and  Nervous  Disturbances  op  Men- 
strual Origin, 353 

XXVI.    Inflammation  of  the  Uterine  Appendages,     .        .  858 

XXVII.    05phoro-Salpingitis  without  Cystic  Tumor,       .       .  362 

XXVIII.    Cystic-Oophoro-Salpingitis, 380 


Contents. 


CHAPTER 

XXIX.    Perdietro-Salpingitis, 

XXX.    Pathological  An'atojiy  of  Ovarian  Cysts,   . 
XXXI.    Etiology,  Syjiptoms,  Progress,  and  Dlvgnosis  of 

Ovarian  Cysts, 

XXXII.    Treatment  of  Ovarian  Cysts 

XXXIII.    Solid  Tumors  of  the  Ovary, 

XXXn".    Tumors  of  the  Fallopian  Tubes  and   of  Broad 

AND  Pound  Ligaments, 

XXXV.    Genital  Tuberculosis 

XXXVI.    Intra-   ant)    Extra-    Peritoneal    Pelvic    Hema- 
tocele  

XXXVII.    Extra-Uterdie  Pregnancy.  . 

XXXVin.    Vagdotis 

XXXIX.    Tumors  of  the  Vagina. 

XL.    Cicatricial  Fistula  of  the  Vagina, 

XLI.    VAGnasMUS, 

XLH.    Laceration  of  the  Perineum, 
XLIII.    Diseases  of  the  Vulva, 
XTiIV.    Esthioment:  of  the  Vulva. 

XLV.    Tumors  of  the  Vulva 

XLVI.    Inflammation  antd  Cy'STs  of  the  G-lands  of  Bar- 
tholin,      

XL^II.      PRURITIS    VuLV^.— CoCCYGODYyiA 

XLVIII.    Wounds   of   the    Vulva    and   Vagina. — Acquired 
Atresias  and  Stenoses.— Foreign  Bodies,  . 
XLIX.    Malformations    of   the   Vulva,  ant)   Hermaphro- 

DISM 

L.  Malformations  of  the  Vagina  and  of  the 

Uterus, 

U.    Accidents  of  Retention  CoNSECurrvE  to  Genital 
Atresias, 


PAGE 

396 
415 

442 
453 

464 

468 
470 

486 
494 
508 
514 
518 
539 
541 
561 
564 
567 

572 
574 

576 


590 
599 


TREATISE  ON  GYNECOLOGY 


CHAPTER  I. 


ANTISEPSIS  IN  GYNiECOLOGY. 

All  the  rules  of  antisepsis  established  for  general  surgery  are 
applicable  to  gynseeology.  There  exist,  however,  particular  de- 
tails and  special  processes  on  which  it  is  essential  to  dwell.  I 
will  divide  this  subject  into  two  portions :  the  first,  relative  to 
operations,  through  the  natural  passages,  on  the  vagina,  the  cervix 
uteri  and  the  uterine  cavity ;  the  second,  pertaining  to  operations 
through  the  abdomen,  to  laparotomies.  Finally  the  preparation 
and  the  care  of  the  most  common  materials  for  ligatures  and 
sutures  will  be  indicated. 

Operations  through,  the  natural  passages.— We  shall 
consider  successively  the  antisepsis  of  :  (a)  the  operator ;  (b)  the 
instruments ;   (c)  the  operating-room,  and  (d)  the  patient. 

A. — The  Operator. — The  nails  should  be  cleaned  with  very  great 
care,  by  the  aid  of  a  pointed  nail-file ;  the  hands  and  arms,  naked 
to  the  elbow,  should  be  scrubbed  in  hot  water  with  a  stiff  brush. 
The  towels  for  drying  should  have  been  sterilized,  if  possible,  in 
the  sterilizing  oven.  All  soaps  are  good,  except  common  hard  soap. 
The  use  of  soap  and  water  should  be  followed  by  bathing  with  a 
sublimate  solution  1-1000.  The  hands  and  forearms  of  every 
person  taking  part  in  the  operation  should  be  cleansed  to  the 
elbows  with  soap  and  water,  then  with  sublimate  solution.*  Some 
operators  are  not  content  with  this  method  and  prefer  to  plunge 
the  hands  and  arms  first  in  a  4-1000  solution  of  permanganate  of 
potash,  which  colors  the  skin  a  brownish  violet,  then  this  stain  is 
removed  by  bathing  in  a  concentrated  solution  of  oxalic  acid  fol- 
lowed by  rinsing  in  sterilized  water.  This  should  be  reserved  for 
exceptional  instances,  as  after  handling  septic  or  suspicious  cases. 

*Furbringer  (Deutsche  Med.  Wochensch,  1889,  No.  48)  defends  the  utilitv  of  bathing 
the  hands  in  90  per  cent  alcohol,  besides  the  sublimate  solution.  This  blunts  the 
sensibility  of  the  fingers  and  I  do  not  employ  it. 


18  Antisepsis  in  Gynecology. 

"When  called  to  handle  fetid  material,  as  in  the  case  of  cancer  of 
the  uterus,  etc.,  besides  antiseptics,  deodorizing  solutions  (which 
should  not  be  confounded  with  the  former)  are  very  useful.  With- 
out these  the  hands  are  impregnated  with  a  disagreeable  odor  that 
they  retain  in  spite  of  all  cleansing.  Foulis,  of  Edinburgh,  has  rec- 
ommended in  these  cases  the  use,  before  operating,  of  the  essence 
of  turpentine,  which  effectually  corrects  the  fetor.  A  dish  contain- 
ing the  sublimate  solution,  1-1000,  should  always  be  near  the 
operator,  so  that  he  can  frequently  bathe  his  soiled  hands.  The 
clothes  of  the  operator  and  his  assistants  should  be  covered  with  a 
long  blouse  or  smock-frock,  which  can  be  changed  and  washed 
after  each  operation.  For  operations  where  there  is  exposure  to 
dampness  from  continued  irrigation,  the  surgeon  should  be  pro- 
tected by  a  waterproof  apron. 

B. — The  Instruments. — The  instruments  should  be  of  the  simplest 
construction,  of  easily  separable  parts,  and  free  from  crevices, 
grooves  or  mountings  which  are  difficult  to  cleanse.  For  this 
reason  the  slides  of  sounds,  tubular  needles  for  sutures,  spring 
needles,  forceps,  and  even,  in  spite  of  their  usefulness,  needles 
with  spring  eyes,  all  should  be  proscribed.  Instruments  in  a 
single  piece  are  the  best.  The  instruments,  which  should  have 
been  immersed  for  five  minutes  in  boiling  water  and  carefully 
dried  after  the  preceding  operation,  are  again  plunged  into  boiling 
water  before  operating,  and  then  placed  in  a  strong  carbolic 
solution  (50-1000).  The  action  of  boiling  water  during  five 
minutes  is  sufficient  to  destroy  the  germs.  Sublimate  solution 
cannot  be  employed  here  on  account  of  its  destructive  action  on 
metals.  If  the  instruments  have  been  previously  employed  in  a 
septic  case  (fetid  pus,  sauious  or  gangrenous  material,  etc.)  these 
precautious  are  not  sufficient.  It  is  necessary  then  to  leave  them 
during  half  an  hour  in  strong  boiling  carbolic  solution,  to  keep  in 
the  sterilizing  oven  at  140-  C.  during  an  hour,  or  to  soak  them  for 
twelve  hours  in  a  cold  carbolic  solution.  These  practices  are  some- 
what injurious  to  instruments,  especially  the  bistouries,  but  they 
are  indispensable. 

C. — Jlie  Operating-Room. — It  is  important  to  operate  in  a  place 
that  has  been  properly  prepared — stripped  of  curtains,  tapestry, 
matting,  carpets,  etc.,  in  which  dust  can  lodge.  In  private  houses 
all  furnitui'e  should  be  removed  when  a  gynjecological  operation 
of  any  importance  is  intended.  In  the  hospital  it  is  necessary  to 
cleanse  daily  the  walls,  ceiling  and  floor  of  the  operating  room.  It 
is  also  well  to  have  sterilized  water  and  antiseptic  solutions  con- 
veniently arranged  in  reservoirs,  furnished  with  ii'rigatiug  tubes, 
so  placed  as  to  be  within  easy  reach  of  the  hand.  In  addition  to 
lateral  illumination  from  a  large  and  high  window,  a  skylight  will 
be  found  exceedingly  useful.    The  furniture  of  the  operating-room 


Antise2}sis  in  GyncBcology.  19 

should  be  as  scanty  as  possible  and  exclusively  of  metal  and  glass, 
easy  to  remove  and  clean. 

D. — The  Patient. — The  patient  should  have  a  bath  (by  preference 
in  sublimate  solution)  the  evening  before  operating  or  on  the  same 
morning.  The  boweles  should  be  carefully  emptied  by  an  ordi- 
nary injection,  and  this  should  be  followed  by  one  of  a  saturated 
solution  of  boracic  acid  (30-1000).  Catheterism  should  be  done 
by  the  operator  or  an  assistant  before  purification  of  the  hands. 
Care  should  be  taken,  in  all  operations  on  the  vulva,  to  shave  the 
hair  to  the  edge  of  the  labia  majora,  as  much  for  the  convenience 
of  the  operator  as  to  prevent  harboring  septic  germs.  The  cleans- 
ing of  the  external  genital  organs  should  begin  with  soap  and  water 
and  a  brush,  then  be  completed  with  sublimate  solution  (1-1000). 
Irrigation  of  the  vagina  is  made  with  the  same  solution,  diluted 
one-half  with  hot  water.  I  consider  the  1-2000  solution  of  corrosive 
sublimate  for  a  vaginal  injection  as  offering  no  danger  when  used 
in  the  conditions  and  according  to  the  principles  indicated  later. 
Corrosive  sublimate  has  recently  been  condemned-f  or  gynaecological 
and  especially  for  obstetrical  use.  It  is  certain  that  it  has  been 
used  with  too  little  care  and  in  too  great  strength.  Accidents  have 
been  observed  not  only  with  injection  of  the  sublimate  solution 
but  also  after  carbolized  injections.  I  will  note,  as  to  this  subject, 
the  danger  in  the  employment  of  impromptu  aqueous  solutions 
prepared  by  diluting  very  concentrated  alcoholic  solutions  of  car- 
bolic acid.  It  may  happen,  especially  if  the  solution  be  impure, 
that  oily  drops  will  form,  and  the  injection,  then,  in  place  of  being 
a  solution,  becomes  a  toxic  mixture.  It  is  equally  certain  that 
intrauterine  injections  with  too  strong  solutions  of  corrosive  subli- 
mate (1-1000)  may  become  harmful,  even  outside  the  puerperal 
state.  It  is  also  necessary  to  recall  the  fact  that  the  ordinary 
solutions  of  sublimate,  when  in  the  presence  of  an  abundant 
secretion,  leucorrhceal,  cancerous,  etc.,  are  in  great  part  rapidly 
neutralized  and  lose  at  once  their  toxic  and  antiseptic  power.  The 
mercurial  salt  is  precipitated  by  the  albuminoid  substances  and 
forms  albuminates,  rapidly  losing  its  antiseptic  properties.  To 
avoid  this  the  solution  is  acidulated  by  adding  tartaric  acid,  5- 
1000,  to  prevent  the  formation  of  albuminates  of  mercury. 

Creoline  has  recently  appeared  and  has  been  tried  in  gynaecology 
and  in  obstetrics.  Apparently  it  has  certain  special  advantages, 
but  also  certain  disadvantages  which  will  restrict  its  use.  It  is 
very  difficult  to  obtain  a  constant  product,  as  its  chemical  com- 
position is  not  yet  definitely  fixed.  It  has  been  employed  in  a 
solution  of  1-200  in  the  treatment  of  perinseal  lacerations,  in 
cracked  nipples,  etc.  More  concentrated  it  may  give  rise  to 
erythema  or  to  eschars.  It  a^jpears  then  inferior  as  an  antiseptic 
to  the  sublimate  solution.     For  intrauterine  injections.  Born  has 


20 


AntisejJs'is  in  Gyiuecology. 


employed  a  solution  of  1-100 ;  for  vaginal  irrigations,  2-100.  He 
has  had  no  accident  from  resori^tiou  and  the  antiseptic  power  has 
appeared  of  real  value.  Creoline  possesses  the  great  advantage  of 
leaA^ing  the  vagina  all  its  suppleness,  and  even  giA'ing  it  an  oily  sur- 
face, which  is  eminently  favorable  to  certain  gynaecological  pro- 
cedures, as  when  several  fingers  are  introduced  into  the  vagina,  or 
in  the  extraction  of  a  voluminous  tumor  (enucleation  of  a  fibroid, 
vaginal  hysterectomy).  It  is  known,  on  the  contrary,  that  solutions 
of  sublimate,  and  even  of  carbolic  acid,  give  the  vaginal  walls  a 
stiffness  and  roughness,  sometimes  inconvenient.  This  is,  I 
believe,  the  sole  usefi;l  application  of  this  new  antiseptic.  Lack 
of  transparency  renders  the  creoline  solution  useless  for  the  im- 
mersion of  instruments. 

Beta  Xajjlithol,  employed  by  Bouchard 
in  intestinal  antisepsis,  has  been  recently 
ad-\-ised  for  dressings  in  aqueous  solution 
or  incorporated  in  gauze.  It  has  the 
advantage  of  being  but  little  toxic,  and 
seems  destined  to  be  of  actual  ser\-ice. 
The  saturated  aqueous  solution  contains 
only  0.2  gi'ammes  per  1000. 

Vaginal  injections,  to  be  perfectly  de- 
tergent, should  be  made  according  to 
certain  rules.  Any  receptacle  fitted  with 
a  rubber  hose,  terminating  in  a  glass  tube 
that  is  easy  to  disinfect  (Fig.  li,  is 
placed  at  a  slight  elevation  or  held  up 
by  an  assistant.  The  person  who  gives 
the  injection  places  the  glass  tube  or 
nozzle  in  the  vagina  and  introduces  by 
its  side  the  index  and  middle  finger, 
pushing  them  carefully  up  to  the  culs- 
de-sac ;  the  fingers  are  then  turned 
about  in  various  directions  with  some 
force,  over  all  the  vaginal  surface  in  such  a  manner  as  to  stretch 
its  folds  and  cleanse  them.  "Without  this  mode  of  procedure  im- 
purities and  infectious  material  always  remain.  The  surgeon  or  his 
chief  assistant  should  see  that  a  vaginal  injection  is  given  before 
every  operation ;  this  is  what  I  call  rinsing  the  vagina.  AU  vagi- 
nal nozzles  for  the  surgeon's  use  are  preferably  of  strong  glass  with 
a  single  terminal  orifice,  for  it  is  toward  the  vaginal  culs-de-sac 
and  the  cervix  that  the  liquid  should  first  be  projected,  the  vagina 
being  cleansed  by  the  return  flow.  For  injections  given  by  the 
patient  herself,  it  is  preferable  to  have  a  nozzle  pierced  with 
several  holes  about  the  bulb  of  the  terminal  end,  to  avoid  the  pos- 
sibility of  introducing  the  liquid  into  the  cervix.    It  is  also  useful 


— Vaginal  injection 
apparatus. 


-  Antisepsis  in  Gynecology.  21 

to  employ  a  -wire-M-ork  speculum  fitted  around  the  nozzle,  for  the 
pvirpose  of  stretching  the  folds  of  the  vagina  and  permitting  a 
more  perfect  cleansing  (Fig.  2).    Every  vaginal  injection  should 


Fig.  2. — Vaginal  tube  and  wire-work  speculum  for  injections. 

be  administered  with  the  woman  in  the  dorsal  position,  with  a 
rubber  sheet  or  a  basin  under  her,  so  furnished  with  a  tube  as  to 
carry  off  the  water.  The  accidents  which  vaginal  injections  may 
produce  have  been  much  exaggerated.  Some  physicians  have  even 
proscribed  the  use  of  injection  tubes,  but  I  believe  this  is  a  grave 
error.  Patients  should  be  instructed  to  introduce  the  tube  not 
more  than  six  to  eight  centimetres,  about  the  length  of  the  finger. 
Eubber  nozzles,  which  cannot  be  cleaned  perfectly  and  made 
aseptic,  should  be  rejected.  Curved  tubes  offer  no  advantage 
over  the  straight.  During  the  week  before  the  operation  the 
patient  should  take  an  antiseptic  injection  (sublimate,  1-2000)  every 
morning  and  evening,  after  which  there  is  placed  in  the  vagina  a 
small  tampon  of  iodoform  gauze.  The  day  of  the  operation  she 
should  take  three  injections  at  intervals  of  an  hour,  the  last  at  the 
moment  of  intervention.  I  will  indicate  later  the  reason  for  this 
mode  of  giving  them.  After  every  antiseptic  injection,  especially 
after  those  of  sublimate,  the  fourchette  must  be  pressed  back  to 
assure  the  complete  escape  of  the  liquid.  Some  women  have 
such  a  tonicity  of  the  vaginal  outlet  that  a  notable  quantity  of 
liquid  can  be  retained  and  give  rise  to  accidents  of  absorption. 

There  is  a  widespread  opinion  that  antiseptic  injections  should 
follow  and  not  precede  the  manipulations  of  minor  gynaecology, 
digital  examinations,  dilatation,  catheterism,  etc.  This  is  a  grave 
error.  It  is  especially  before  that  antisepsis  is  necessary.  Steffeck 
has  made  very  exact  researches  on  the  subject  of  the  germs  natural 
to  the  female  genitalia,  of  which  the  folloMing  is  an  instructive 
resume:  1.  After  simple  vaginal  injection  of  a  litre  of  a  solution 
of  sublimate  (1-3000)  as  many  germs  are  found  in  the  cervix  as 
before,  the  vagina  only  is  cleansed.  2.  After  the  same  injection, 
aided  by  vaginal  cleansing  with  one  finger,  or  inoculating  agar-agar 
with  vaginal  mucus,  there  are  seen  to  develop  colonies,  less  numer- 
ous it  is  true,  but  still  very  abundant.  3.  After  the  same  pro- 
cedure with  two  fingers,  two  cultures  out  of  three  are  sterile.     4. 


22  Antisepsis  in  GyiKecology. 

In  a  last  experiment,  the  injection  of  the  vagina  and  the  cleansing 
of  the  cervix  are  made  in  the  following  manner :  One  linger  is 
pushed  into  the  neck  as  deeply  as  possible,  another  finger  is  pushed 
into  the  anterior  cul-de-sac  to  cleanse  it,  then  the  two  fingers 
change  places  in  a  way  to  cleanse  the  posterior  cul-de-sac.  The 
jet  of  the  injection  is  finally  directed  exactly  on  the  orifice  of  the 
cervix.  In  consequence  of  this  effectual  cleansing,  all  attempts 
at  culture  remain  sterile,  while  before  this  disinfection  the  cultui-e 
gave  fifty  to  one  hundred  colonies.  The  same  good  results  were 
obtained  with  the  carbolic  solution,  3-100.  But,  as  could  be  fore- 
seen, this  disinfection  is  only  temporary,  the  germs  descend  from 
the  supravaginal  part  of  the  cervix  into  the  mucus  of  the  os.  Thus 
at  the  end  of  an  hour  germs  are  again  found  in  the  inferior  portion 
of  the  cervix.  There  is,  however,  a  means  of  destroying  them  for 
a  long  period,  that  is  to  make  a  second  injection,  with  the  same 
precautions,  an  hour  after  the  first,  then  a  third  an  hour  after  the 
second.  The  mucus  which  flows  now  contains  no  germs,  and 
Steffeck  has  been  able  to  show  that  they  did  not  return  at  the  end 
of  five  days.  This  procedure  of  successive  sterilization  is  a  long 
one,  but  it  reduces  to  a  minimum  the  chances  of  auto-infection. 
This  is  why  I  recommend  the  administration  of  three  consecutive 
injections,  at  intervals  of  an  hour,  before  every  operation.  The 
uterine  sound  should  never  be  used,  nor  should  a  dilating  instru- 
ment be  employed,  before  this  disinfection  of  the  vagina  and  cervix 
by  thi-ee  injections.  The  absence  of  this  precaution  accounts  for 
the  numerous  accidents  caused  by  these  manoeuvres  even  when 
apparently  surrounded  by  antiseptic  precautions.  If  there  is  an 
affection  giving  rise  to  a  disagreeable  odor,  cancerous  vegetations, 
gangrenous  fibroids,  etc.,  the  antiseptic  injection  should  be  pre- 
ceded by  a  deodorizing  injection  of  a  litre  of  boiled  water  to  which 
has  been  added  a  variable  quantity  of  Labarraque's  solution.  For 
cleansmg  the  rectum  or  of  the  bladder  there  may  be  used  either  a 
boracic-acid  solution  (30-1000)  or  a  solution  of  salicylic  acid 
(1-1000),  as  these  are  non-irritating  to  the  mucous  membranes. 

Iodoform  Game. — The  iodoform  gauze  commonly  employed  is 
furnished  ready  made  from  the  manufacturer.  It  is  supposed  to 
contain  20  to  30  per  cent  of  iodoform.  It  is  preferable  in  hospital 
service  to  have  this  prepared  by  a  reliable  person.  It  may  be  ob- 
tained by  impregnating  a  piece  of  gauze  (previously  sterilized  by 
boiling),  ten  metres  long,  cut  in  sections  of  one  metre,  with  the 
following  solution : 

3  Iodoform,  50  grammes; 
Glycerine,  loo  grammes; 
Ether,  7CXJ  grammes. 

This  gauze  is  passed  through  a  wringer  and  then  suspended  in 
a  heat  of  80'  C.  to  dry  it.     Finally  it  is  preserved  in  well  closed 


Antisejms  in  Gyncecology,  23 

tin  boxes.  If,  in  consequence  of  symptoms  of  absorption,  it  be- 
comes necessary  to  replace  the  iodoform  gauze  by  another  topical 
application,  sublimate  gauze  1-1000  is  used.  This  may  easily  be 
obtained  by  boiling  ordinary  gauze,  for  an  hour,  in  a  solution  of 
carbonate  of  soda,  20-1000,  to  remove  all  debris,  then  an  hour  in 
the  sublimate  solution,  1-1000. 

I  have  employed  salol  and  iodol,  but  have  found  them  inferior 
to  iodoform  and  corrosive  sublimate.  With  regard  to  carbolic 
gauze  it  rapidly  loses  its  antiseptic  property,  so  it  is  unreliable 
and  it  is  also  a  little  irritating. 

Antisepsis  of  the  cervix  and  of  the  uterine  cavity. — 
After  operations  on  the  uterus  and  cervix  an  antiseptic  is  some- 
times left  in  the  eer\-ical  canal.  I  have  used  small  suppositories 
after  the  formula  of  von  Hacker : 

g    Iodoform,  20  grammes ;  3  v 

Gum  arable, 
Glycerine, 

Starch,  a  a,  2  grammes.         gr.  xxx 
Make  into  suppositories  the  size  of  the  ordinary  crayon  of  nitrate  of  silver. 

These  suppositories  have  the  advantage  of  being  easily  managed 
and  easily  pushed  far  into  the  uterus;  but -sometimes  (omng  no 
doubt  to  a  fault  in  preparation)  they  dissolve  incompletely  and 
provoke  colic.  I  have  now  abandoned  them,  and  simply  powder 
the  cervix  with  iodoform  or  insufflate  the  canity,  finally  leaving 
an  iodoform  gauze  tami^on  in  contact  with  the  cervix. 

The  disinfection  of  the  agents  for  dilation  of  the  cervix  is  one  of 
the  important  points  of  our  study.  I  believe  tupelo  and  prepared 
sponge  are  inferior  to  laminaria.  They  have  often  been  a  source 
of  infection,  in  spite  of  precautions.  There  is  a  choice  between 
two  procedures  of  making  tents  antiseptic  :  either  immersion  in  a 
concentrated  solution  of  carbolic  acid  in  rectified  alcohol,  or  leav- 
ing them  in  a  saturated  solution  of  iodoform  in  ether,  to  which  is 
added  a  tenth  part  of  alcohol.  Whatever  the  preparation  may  be, 
it  is  necessary  before  employing  the  laminaria  to  wash  it  quickly 
in  a  carbolic  solution  20-100,  or  sublimate  1-1000. 

Intrauterine  injections,  in  gynaecology,  are  far  from  having  the 
the  same  dangers  as  in  obstetrics.  It  is  necessary,  however,  to 
except  cases  where  the  uterine  cavity  is  much  dilated  and  presents, 
after  an  operation,  a  large  denuded  surface  (enucleation  of  fibroids, 
curetting  of  a  cancer  of  the  body  of  the  uterus,  etc.).  In  these 
cases,  in  fact,  the  conditions  resemble  somewhat  those  in  which 
the  uterus  is  found  after  delivery,  in  respect  to  the  facility 
for  absorption.  When  the  uterine  cavity  is  notably  dilated  (ex- 
ample :  after  curetting  a  catarrhal  or  hemorrhagic  metritis)  the 
sublimate  solution,  1-2000,  can  be  employed  without  inconvenience 
if  there  is  used  a  double-current  canula  of  hard  rubber,  of  glass, 
or  of  celluloid.    But  most  instruments  being  of  metal,  which 


24   ■  Antisejjsis  in  Gymecology. 

sublimate  attacks,  it  is  preferable  to  use  a  carbolic  solution  of 
10-1000.  The  solution  should  be  lukewarm,  aud  a  half  litre  or 
more  cau  be  used,  until  the  uterine  cavity  is  known  to  be  clean  by  the 
appearance  of  the  returning  liquid.  The  number  of  instruments 
for  intrauterine  injections  has  largely  increased  of  late.  When 
the  uterine  cavity  is  not  enlarged  I  use  the  Bozemann  model  (Fig. 
8),  after  rapid  dilatation  of  the  cervix  if  necessary.  If  the  uterus 
is  much  enlarged  injection  with  an  ordinary  cauula  exposes  to  no 
danger  if  the  pressure  is  not  too  great,  the  reflux  of  the  liquid  easily 
taking  place  tkrough  the  sound.  When  there  is  need  of  energetic 
disinfection  of  the  uterus  (as  in  cases  of  gangrenous  fibroids,  intra- 
uterine cancer  with  putrid  fungosities,  etc.),  the  injection  of 
sublimate,  1-2000,  is  preferable  ;  after  using  a  large  quantity  it  is 


Fig.  3. — Bozemann's  Intrauterine  Back-flow  Tube. 

necessary  to  follow  this  with  another  indifferent  irrigation  (intra- 
uterine) capable  of  ensuring  complete  evacution  of  the  toxic  anti- 
septic. For  this  I  recommend  sterilized  Avater  with  the  addition 
(6-1000)  of  sea  salt.  This  addition  modifies  the  endosmotic  and 
irritating  properties  by  approximating  the  composition  of  blood 
serum.  I  use  this  liquid  extensively  for  simple  aseptic  irrigation 
in  all  cases  where,  for  various  reasons,  the  action  of  an  antiseptic 
has  disadvantages. 

Continued  irrigation  during  operation. — This  can  be 
practiced  by  means  of  a  special  speculum  or  simply  by  means  of 
a  long  canula  that  one  of  the  assistants  holds  in  one  band,  taking 
a  point  of  support  on  the  pubes,  while,  with  the  same  baud,  lie 
manages  a  valve  or  stop-cock  (Fig.  4).  The  liquid  that  I  employ 
for  irrigation  is  carbolized  water,  10-1000,  of  35"  C.  to  40^  C.  temper- 
ature. It  is  necessary  to  lower  the  proportion  to  5-1000  if  the 
irrigation  be  prolonged,  owing  to  the  danger  of  producing  painful 
excoriations.  The  fine  jet  of  water  which  flows  over  the  field  of 
operation,  under  a  control  that  modifies  its  activity  at  will,  has  a 
double  advantage :  it  clears  away  the  blood  unceasingly  and  dis- 
penses with  sponges  or  their  equivalants,  and  more  than  this  it 
keeps  the  wound  bathed  in  an  antiseptic  liquid  and  is  better  pro- 
tection than  spray  against  the  germs  from  the  air.  'The  employ- 
ment of  continued  irrigation  is  the  rule  for  all  operations  I  perform 
on  the  vTilva,  the  vagina,  the  cervix.  It  cannot  be  recommended 
too  higlily.  I  never  use  sponges ;  pledgets  of  absorlient  cotton, 
either  dry  or  impregnated  with  sublimate  solution  and  then  strongly 


Antisepsis  in  Gi/iuecolo<jij.  25 

squeezed  out,  take  their  place  advantageously.    When  employed 
dry  it  is  better  to  envelope  the  cotton  pledgets  with  gauze. 


Fig  4 — Irrigation  during  operation  ,  positions  of  the  assistants. 

Laparotomy. — We  come  to  the  special  antiseptic  precautions 
which  concern  laparotomy.  A  grave  question  presents  itself,  How 
is  it  that  operators  of  high  repute,  Lawson  Tait  and  Bantock,  for 
example,  denounce  antisepsis  as  useless  and  even  dangerous,  yet 
attain  without  it  such  magnificent  results  ?  Does  not  this  pre- 
emptorily  invalidate  the  usefulness  of  the  minute  precautions 
that  we  shall  recommend?  The  contradiction  is  less  in  reality 
than  in  appearance  and  to  be  convinced  of  this  it  is  sufficient  to 
follow  in  its  details  the  method  of  the  operators  that  I  have  cited. 
Itwiirbe  seen  that  if  they  are  not  antiseptic  they  are  to  the  highest 
degree  aseptic.  Now,  for  the  principal  stages  of  laparotomy  (for 
all  intraperitoneal  manoeuvers),  asepsis  is  not  only  equal,  but  even 
superior  to  antisepsis.  In  fact,  considering  the  great  delicacy 
of  the  epithelium  of  the  serous  membranes,  the  employment  of  an 
antiseptic  solution  strong  enough  to  be  active,  profoundly  alters  it 
and  may  produce  grave  sequellte.  Kigorous  asepsis  should,  then, 
be  observed  in  the  abdomen,  while  antisepsis  is  reserved  for  the 
exterior.  If  it  is  remarked  also,  that,  after  laparotomy  and  ac- 
curate suture  of  the  abdominal  walls,  there  exists,  so  to  speak,  no 
wound,  it  will  be  easily  understood  that  the  omission  of  antiseptics 
from  the  dressings  will  be  of  little  importance.  I  consider  it, 
however,  a  mistake. 

A. — Operation. — Operator  and  assistants  should  be  aseptic.  None 


26  Antisepsis  in  Gi/ncecolufifj. 

of  the  assistants  should  have  heen  in  a  dissecting-room,  made  a  post- 
mortem, nor  touched  pathological  specimens  or  a  septic  wound, 
during  the  forty-eight  hours  previous  to  the  operation.  If  so,  he 
should  have  taken  a  bath  of  sublimate  solution  vnth  energetic 
scrubbing  of  the  whole  body  with  soap  and  water.  A  long  garment, 
absolutely  clean,  should  cover  the  clothes.  The  hands  and  arms 
should  be  disinfected  as  indicated  before.  Care  should  be  taken 
not  to  touch  any  object  (not  disinfected)  nor  to  shake  hands  with 
any  one  after  the  ablutions.  If  necessary,  sterilize_d  gloves  can  be 
kept  in  the  sterilizer  to  protect  the  cleansed  hands  until  the 
moment  of  operation.  The  number  of  assistants  will  be  as  limited 
as  possible,  to  diminish  the  chance  of  infection.  One  is  ordinarily 
sufficient  for  the  operation  itself;  a  second  to  prepare  and  pass 
ligatures  and  sutures.  The  operator  himself  should  take  his  in- 
struments from  the  tray,  where  they  remain  immersed.  It  is 
necessary  to  abstain  from  all  abdominal  operations  if  there  is  the 
least  pustule  or  suppurating  erosion  on  the  hands ;  no  rubber  linger 
will  be  sufficient  protection  against  the  possible  infection  of  the 
the  peritoneum. 

B. — Tlie  Patient. — The  patient  has  taken  the  previous  evening  a 
bath  of  sublimate  solution  or  of  soap  and  water.  For  several  days 
she  has  had,  morning  and  evening,  a  vaginal  injection  of  sublimate 
solution,  1-2000,  and  a  tampon  of  iodoform  gauze  has  been  placed 
in  the  vagina  immediately  before  operation.  The  bowels  have 
been  evacuated  the  evening  before  by  purgation,  and  the  same 
morning  bj'  an  enema.  The  assistant  uses  the  catheter  and  dis- 
infects himself  at  once.  The  hair  is  shaven  from  the  field  of 
operation,  the  abdomen  is  cleaned  with  soap  and  water  and  a  brush, 
then  with  ether,  and  lastly  with  corrosive  sublimate,  1-1000. 
Especial  care  is  taken  in  cleaning  the  folds  of  the  umbilicus.  The 
abdomen  is  now  covered  with  compresses,  soaked  in  sublimate 
solution,  during  the  time,  however  short,  between  the  cleansing 
and  the  operation. 

C. — The  Ojwmtinfi-Room. — At  the  hospital  a  special  room  should 
be  reserved  for  laparotomies.  It  should  be  as  far  as  possible  from 
the  common  wards,  where  there  are  suppurating  or  septic  wounds 
from  water  closets,  and  in  general  from  all  sources  of  infection.  The 
angles  should  be  rounded  and  it  should  have  no  recesses  or  surfaces 
difficult  of  access  for  rapid  and  complete  cleaning.  All  furniture 
should  be  easily  removed  and  exclusively  constructed  of  varnished 
or  enameled  metal  or  glass.  After  each  operation  a  general  wash- 
ing of  the  room  should  be  made  with  a  hose  attached  to  a  pump  or 
to  a  faucet  bringing  water  under  a  pressure  sufficient  to  reach  the 
most  distant  parts. 

If  the  operation  is  not  in  the  hospital,  a  room  should  be  prepared 
at  least  two  days  l)efore  the  intended  laparotomy.     It  should  be 


Antisepsis  in,  Gyiuecology.  27 

deprived  of  all  its  furniture.  If  its  walls  cannot  be  whitened  with 
lime,  they  can  be  perfectly  purified  as  well  as  the  floor,  the  ceiling 
and  wainscoting  by  covering  them  -with  cloth  impregnated  with 
carbolic  solution,  50-1000.  If  the  house  be  old  or  the  room  sus- 
pected there  must  be  added  to  this  cleansing,  disinfection  with 
sulphurous  acid,  by  throwing  sulphur  on  some  lire  coals  in  the 
middle  of  the  room,  before  leaving  it,  and  closing  it  hermetically 
during  one  day. 

The  temperature  should  be  raised  during  the  operation  to  avoid 
chilling  the  patient.  A  temperature  of  '25°  C.  at  minimum  and  Q(f 
C.  at  maximum  is  necessary.  That  the  heat  may  not  be  too  dry 
— this  will  be  one  of  the  greatest  dangers  for  the  exposed  viscera — 
take  care  to  saturate  the  atmoshere  with  carbolic  vaper  by  the  aid 
of  a  steam  atomizer.  This  spray  should  not  be  projected  on  the 
field  of  operation,  as  during  the  early  days  of  Listerian  antisepsis 
and  as  some  operators  still  maintain.  The  spray  should  be  directed 
towards  the  middle  of  the  room,  and  a  little  upward.  The  sole 
effect  we  seek  is  the  saturation  of  the  atmosphere.  When  this  is 
obtained  the  spray  is  stopped,  and  only  renewed  if  needed  by 
reason  of  a  prolonged  operation.  Constantly  directed  on  the  patient 
the  spray  is  of  more  harm  than  use,  it  chills  and  irritates  the 
peritoneum  beyond  measure,  without  speaking  of  the  dangers  of 
poisoning. 

D. — Instrivnients. — The  instruments  must  be  perfectly  clean, 
having  been  plunged  in  boiling  water  during  five  to  ten  minutes 
after  the  preceding  operation.  The  day  of  the  operation  they 
should  be  placed  for  an  hour  in  the  sterilizer  maintained  at  120°C. 
to  140°  C.  (Fig.  5),  then  immersed  in  the  carbolic  solution,  60-1000. 
Cutting  instruments  subjected  to  these  processes  quickly  deteriorate 
and  will  need  frequent  sharpening.  I  recommend  the  operator 
never  to  use  borrowed  instruments.  Your  own  instruments  are  the 
only  ones  that  you  can  be  sure  are  aseptic.  Better  a  badly-cutting 
bistoury  that  is  aseptic  than  a  sharp  bistoury  that  is  septic. 

I  have  abandoned  sponges.  Sponges  are  open  to  suspicion  and 
may  be  easily  dispensed  Avith.  This  last  consideration,  which  will 
astonish  some  perhaps,  is  not  a  matter  of  indifference  in  the 
hospital.  Having  been  a  witness  in  the  clinic  of  Billroth  of  the 
advantages  offered  in  laparotomies  by  antiseptic  compress-sponges, 
I  have  adopted  their  use  exclusively.  They  are  prepared  as  follows : 
A  piece  of  gauze  is  folded  so  as  to  form  squares  of  thirty  centimetres 
composed  of  eight  thicknesses  of  cloth.  These  compresses  are 
fastened  at  several  points  along  each  border.  Then  they  are  boiled 
for  two  hours  or  less  either  in  carbolic  solution  50-1000,  or  in  subli- 
mate 1-1000.  Finally  they  are  preserved  in  a  fresh  solution  of  the 
same,  which  should  be  changed  every  week.  Before  using  they 
should  be  carefully  washed  in  sterilized  water  and  wrung  as  dry  as 


28 


Antlsej^sis  in  Gyiuecolcfii/. 


possible.  They  then  constitute  a  powerful  absorbent  agent,  which 
can  be  quickly  given  any  form  or  dimension,  can  be  ^Tapped 
around  the  finger  in  penetrating  into  cavities  or  interstices,  when 
exposing  the  intestines,  wliich,  in  a  word  offers  advantages  much 
superior  to  those  of  sponges.  During  an  operation  the  same  com- 
press can,  if  necessary,  serve  several  times  without  cleansing.  Those 
■which  have  been  contaminated  by  septic   material   are   at  ouce 


Fig.  5. — Wiesnegg's  sterilizer.     A,  regulator;  B,  burners;  C,  thermometer. 

thrown  away.  After  each  operation  aU  are  destroyed.  Their  in- 
signifieaut  cost  justifies  this  sacrifice  which  would  be  costlj'  for 
sponges. 

"With  regard  to  the  antiseptic  procedures,  which  are  part  of  the 
operation  itself,  I  will  be  very  brief  and  confine  myself  to  a  simple 
enumeration  returning  to  this  subject  in  treating  of  each  particular 
operation.     I  will  only  note  those  of  special  importance  : 

Toilet  of  the  peritonaeum. — (a).  Laparotomists  have,  for  a 
long  time,  gone  to  extremes  in  their  anxiety  to  relieve  the  perito- 
neum of  all  effused  liquid  and  clots  of  blood..  The  noxious  action 
of  these  residues  has  been  exaggerated.  They  can  be  perfectly 
absorbed  if  the  absorbent  power  of  the  serous  membrane  has  not 
been  destroved  bv  lotions  or  by  uncalled  for  rubbing.     Be  very 


AntisejJsis  in  Gyncecology .  29 

reserved  in  the  toilet  of  tlie  peritonaeum,  and  endeavor  to  make 
it  unnecessary  by  avoiding  contamination  with  the  contents  of 
tumors.  If  this  cannot  be  prevented,  cleanse  rapidly  with  the 
compress-sponges.  According  to  some  authorities,  some  reputedly 
very  infectious  liquids,  as  the  contents  of  cysts,  the  pus  of  an  old 
pyosalpinx,  are  much  less  dangerous  than  has  been  believed. 

(b) .  The  copious  peritoneal  irrigation  with  sterilized  warm  water 
(to  wliich  I  add  6-1000  of  chloride  of  sodium)  was  first  advised  by 
LaAvson  Tait  and  is  esi^ecially  employed  in  case  an  irritating  or 
infectious  liquid  has  contaminated  the  serosa  during  the  operation, 
but  it  should  not  be  abused  for  removing  the  blood,  as  this  is  better 
done  with  the  compress-sponge.  If  it  is  dangerous  to  leave  in  the 
peritoneal  cavity  the  least  drop  of  pus  or  the  least  septic  bit  it  is 
not  so  of  small  clots,  Avhich  are  easily  absorbed.  Irrigations  of 
hot  water  have  one  other  indication  which  I  only  mention  in  pass- 
ing. They  have  been  vaunted  as  a  means  of  combating  the  ex- 
cessive depression  of  the  patient,  the  sliock.  Polaillon  has  recently 
noted  the  danger  of  flushings  with  too  hot  water  on  the  subumbilical 
portion  of  the  peritonaeum  in  the  vicinity  of  the  solar  plexus. 
They  may  provoke  arrest  of  respiration  and  syncope.  With  regard 
to  their  use  in  the  pelvic  cavity,  they  are  dangerous  only  if  not 
made  quickly  and  if  other  than  an  innoxious  fluid  be  employed,  as 
there  is  danger  of  absorption. 

(c).  Cauterization  of  cut  surfaces,  pedicles  and  adhesions,  has 
been  made  with  an  antiseptic,  such  as  strong  carbolic  solution, 
tincture  of  iodine,  iodoform,  or  with  the  actual  cautery.  This  last 
I  employ  frequently,  especially  every  time  the  cut  surface  is  open 
to  suspicion  (as  in  certain  salpingotomies),  or  even  only  thick  and 
succulent.  I  only  speak  here'  of  cauterization  as  an  antiseptic 
and  not  of  its  haemostatic  properties. 

Preparation  and  preservation  of  the  materials  for 
ligatures  and  sutures. — I  will  close  these  remarks  on  gynaeco- 
logical antisepsis  by  indicating,  by  way  of  appendix,  the  mode  of 
preparation  and  preservation  of  the  principal  ligatures  and 
sutures : 

Silk. — The  most  tenacious  silk,  for  its  size,  is  the  flat,  plaited 
preparation  (made  in  six  sizes).  It  is  disposed  in  very  loose 
skein  (an  important  precaution  for  equal  and  perfect  disinfection) 
and  boiled  an  hour  in  a  carbolic  solution,  50-1000.  It  is  then 
wound  on  glass  plates  and  immersed  in  a  fresh  solution  of  the 
same,  which  is  renewed  every  eight  days.  It  is  better  not  to  pre- 
pare too  much  silk  in  advance  as  it  is  more  perfectly  aseptic  if 
used  soon  after  boiling.  Hegar  prepares  silk  with  iodoform.  It 
is  immersed  for  twenty-foi^r  hours  in  a  solution  of  iodoform  in 
ether  (20-100),  then  dried,  rolled  on  bobbins,  placed  in  a  glass  box 
and  covered  with  iodoform.     The  silk  can  also  be  made  aseptic 


30  Antisejisis  in  Gyncecology. 

by  boiling  in  sublimate  solution,  1-1000.  For  myself,  in  laparo- 
tomies, I  prefer  the  carbolized  silk,  as  there  is  less  toxic  exposure 
where  numerous  sutures  are  made  and  where  a  quantity  is  left  in 
the  abdomen.  Some  feeble  patients  have  an  extreme  susceptibility 
to  corrosive  sublimate. 

Catgut. — The  preparation  which  has  given  me  the  best  results,  is 
that  in  the  oil  of  juniper.  After  an  hour  of  immersion  in  the  sub- 
limate, 1-1000,  I  plunge  the  rolls  of  catgut  into  juniper  oil  for  at 
least  eight  hours;  they  are  then  taken  out  and  preserved  in 
alcohol  with  the  addition  of  a  tenth  part  of  juniper.  At  the  time 
of  using,  the  catgut  is  placed  in  the  sublimate  solution,  1-1000,  for 
a  few  minutes,  which  slightly  swells  it,  but  gives  it  a  greater  plia- 
bility. The  advantages  of  juniper  catgut  are  considerable,  it  is 
much  superior  to  the  ordinary  catgut  disinfected  by  carbolized  oil. 
Its  tenacity  and  flexibility  are  remarkable.  It  serves  for  buried 
sutures,  for  it  is  dissolved  and  absorbed  at  the  end  of  a  time  pro- 
portionate to  its  size.  August  Eeverdin  leaves  the  catgut  for  four 
hours  in  a  sterilizer  at  140°  C.  before  placing  in  jumper  oil  and 
preserving  in  alcohol.  Previous  to  this  the  fatty  substances  are 
removed  by  treating  the  catgiat  with  ether.  Beackizer  has  adopted 
disinfection  by  heat,  enclosing  small  quantities  of  catgut  in  sealed 
envelopes  before  placing  in  the  sterilizer,  and  only  breaking  the 
packages  at  the  time  of  the  operation.  Some  surgeons  prefer  cat- 
gut that  is  carbolized  or  prepared  with  corrosive  sublimate.  Catgut 
prepared  in  carbolic  oil  is  always  oily  and  disagreeable  to  handle. 
Mikulicz  has  a  mode  of  preparation  which  transforms  the  catgut 
into  a  remarkably  resistant  and  tenacious  suture.  The  catgut  is 
first  placed  in  carbolized  glycerine,  1-1000,  for  forty-eight  hours, 
then  during  five  hours  in  a  chromic-acid  solution,  -1-100,  finally 
■  preserved  in  absolute  alcohol. 

Silver  wire  and  Silk-worm  gut  are  preserved  in  alcohol  after  being 
heated  to  120°  C.  in  the  sterilizer.  Cords  and  tubes  for  elastic 
ligatures  and  drainage  tubes,  are  obtained  relatively  pure  by 
leaving  them  ten  minutes  in  boiling  water,  then  preserving  in 
strong  carbolic  water  or  solution  of  sublimate  in  well-corked 
bottles.  However,  tliis  does  not  insui-e  perfect  disinfection,  as  this 
temperature  does  not  destroy  germs.  As  the  sterilizer  at  120°  C. 
destroys  the  rubber,  we  accomplish  perfect  asepsis  by  lea^dng  them 
for  five  days  in  water  at  about  85'  C,  renewing  the  water  every 
day.  Then  they  can  be  placed  in  the  sublimate  solution,  or  in  the 
carbolic,  60-1000,  changing  the  solution  every  two  days  during  a 
fortnight.  At  the  end  of  this  time  they  may  be  used  with  entire 
security. 


AncBSthesia  in  Gynmcology.  31 


CHAPTER  11. 


AN-ffiSTHESIA  IN   GYNECOLOGY. 

Local  anaesthesia  can  often  be  utilized  in  various  operations  on 
the  skin  and  mucous  membranes.  For  an  incision  or  rapid  dis- 
section refrigeration  by  a  mixture  of  pounded  ice  and  salt  can  be 
employed.  It  is  necessary  to  seize  the  moment  when  the  skin 
blanches  and  not  prolong  the  action  of  the  cold,  as  it  disposes  to 
vesication  and  eschars.  A  convenient  mode  is  spraying  with  ether, 
but  this  is  too  well  known  to  require  explanation.  It  has  the  dis- 
advantage of  being  slow  and  of  proscribing  the  use  of  the  thermo- 
cautery. Other  authors  have  proposed  replacing  ether  by  a  spray 
of  the  non-inflammable  bromide  of  ethyl,  but  this  offers  other  dis- 
advantages which  prevent  its  general  use.  Cocaine  can  be  em- 
ployed for  anaesthesia  of  the  skin.  A  hypodermic  injection  of  a 
5-per-cent  solution  produces  in  one  to  two  minutes  an  anaesthesia 
which  lasts  twenty  to  twenty-five  minutes.  The  anaesthetic  zone 
extends  over  a  surface  of  two  to  three  centimetres,  and  there  exists 
a  second  zone  of  semi-anaesthesia  of  similar  extent,  carrying  to 
four  or  six  centimetres  square  the  surface  which  can  be  operated 
on  without  pain,  for  twenty  to  twenty-five  minutes.  This  is  more 
than  is  necessary  for  opening  a  small  abscess  or  to  extripate  a 
small  tumor.  "With  regard  to  a  mucous  surface,  painting  with  a 
one-tenth  solution  is  preferable ;  an  anaesthesia  is  thus  obtained 
that  can  easily  be  prolonged  by  repeated  applications.  Hank's 
observation  must  be  noted  as  he  accuses  the  use  of  cocaine  of  a 
bad  effect  on  the  reunion  of  plastic  operations.  Does  not  this  ap- 
pear to  be  due  to  painting  the  wound  with  a  non-sterile  solution  of 
cocaine  ?  The  solution  should  be  made  only  with  distilled  water, 
boiled,  and  should  have  some  drops  of  von  Swieten's  solution. 
However  it  is  necessary  to  exercise  moderation  in  injections  as 
accidents  have  followed  their  use.  It  does  not  appear  prudent  to 
exceed  a  dose  of  five  centigrammes,  or  twenty  drops  of  a  5-per- 
cent solution,  of  cocaine  hydrochlorate.  Eeclus  wrongly,  in  my 
opinion,  does  not  hesitate  to  go  as  high  as  twenty  centigrammes. 

Continual  irrigation,  besides  its  antiseptic  use,  also  moderates  the 
pain  remarkably,  when  it  is  made  with  a  weak  carbolic  solution 
(10-1000). 

Finally,  among  hysterical  or  very  nervous  females,  it  is  possible 
to  obtain  sufficient  anaesthesia  by  hypnotic  suggestion.  I  note  this 
fact  mainly  as  a  pathological  curiosity.     However,  I  have  practiced 


32  Ancesthesia  in  Gynecology. 

curetting  several  times  -svitbout  pain,  by  suggesting  to  the  patient 
that  she  would  not  suffer  and  that  there  was  no  need  for  anesthesia. 

General  anaesthesia  is  indispensable  for  all  major  operations. 
It  may  be  employed  even  in  minor  gynaecology  when  properly 
watched.  Thus  I  usually  anaesthetize  for  curetting  the  uterus.  It 
is  indispensable  to  anaesthetize  for  all  examinations  relating  to 
the  abdominal  organs.  Exploration  is  much  facilitated  by  the 
flaccidity  of  the  abdominal  walls  and  by  the  absence  of  the  reflex 
effects  that  result  from  pain.  Anaesthetic  exploration  should  be 
the  rule  in  the  larger  proportion  of  cases ;  without  this  it  is  often 
impossible  to  obtain  sufficient  knowledge  of  the  state  of  the  uterine 
appendages  in  inflammation  of  these  organs. 

Lawson  Tait,  Keith  and  a  number  of  English  operators  prefer 
ether  to  chloroform,  as  it  gives  rise  less  frequently  to  excitement 
and  vomiting.  But  ether  has  been  accused  of  having  a  noxious 
effect  on  the  renal  epithelium,  which  renders  its  use  dangerous 
when  the  kidneys  are  affected,  as  is  frequently  the  case  in  ab- 
dominal tumors.  Manj'  German  laparotomists  use  a  mixture  of 
chloroform  and  alcohol,  the  anaesthesia  being  more  even  and  the 
vomiting  less  frequent.  In  France  chloroform  reigns  almost 
supreme.  Its  purity  should  be  assured,  especially  when  the 
anaesthesia  is  prolonged. 

In  subjects  particularly  nervous  and  excitable  I  find  it  of  use, 
just  before  beginning  the  administration  of  chloroform,  to  give  a 
hypodermic  injection  of  one  centigramme  and  a  half  (twenty-five 
or  thirty  drops)  of  the  following  solution  : 

g   Distilled  water,  10  grammes;  lo. 

Chlorhydrate  of  morphia,  10  centigrammes;  ,oi 

Sulphate  of  atropia,  5  milligrammes.  .005 

This  injection  is  given  fifteen  or  twenty  minutes  before  ad- 
ministering cliloroform.  A  more  regular  sleep  and  of  longer  duration 
is  thus  obtained  with  smaller  doses  of  chloroform.  The  care  of 
the  anaesthesia  is  made  imcomparably  easy  and  I  cannot  recom- 
mend this  method  of  mixed  anaesthesia  too  highly  for  operations  of 
long  duration.  The  patient  is  anaesthetized  in  her  bed  and  carried 
to  the  amphitheatre,  the  emotions  produced  by  the  sight  of  the 
surgical  preparations  are  thus  avoided  and  the  beginning  of  anaes- 
thesia is  less  troublesome.  It  is  always  necessary  to  remember  that 
prolongation  of  the  anaesthesia  is  a  serious  matter.  It  is  dangerous 
for  the  nervous  system,  it  is  dangerous  by  its  action  on  the  kidneys. 
Many  cases  reported  under  the  head  "  sJiock"  surely  bear  evidence 
of  the  depressing  influence  on  the  nervous  system  of  an  anaes- 
thesia of  more  than  two  or  even  three  hours,  as  one  of  the  impoiiant 
causes  of  the  fatal  termination.  It  is  the  same  perhaps  with  a 
certain  number  of  accidents  regarded  as  reflexes,  observed  after 
utero-ovarian  operations,  and,  in  pai-ticular,  that  which  has  been 


Ancesthesia  in  Giinacology.  33 

called  the  guttural  reflex,  cbaracterized  by  painful  and  incessant 
spitting.  I  have  observed  this  symptom  after  long  operations 
other  than  abdominal  and  I  believe  that  it  is  due  to  a  true  poison- 
ing by  chloroform.  On  the  other  hand,  the  absorption  of  a  large 
quantity  of  chloroform  or  ether  and  its  subsequent  elimination  by 
the  kidneys  determines  an  intense  congestion,  with  or  \vithout 
albuminuria.  This  enters  without  doubt  into  a  large  part  of  the 
dyspnoeic  accidents  noted  in  consequence  of  laparotomy.  It  is 
especially  after  abdominal. hysterectomies  that  these  disturbances 
of  the  cardio-pulmonary  apparatus  have  been  observed ;  now  we 
shall  see  that  the  kidneys  are  more  particularly  M.ilnerable,  for  while 
all  abdominal  tumors  predispose  to  cln-onic  nepln-itis,  this  is  never 
observed  as  often  as  in  fibroid  tumors.  The  renal  filter  is  then 
very  defective,  powerless  to  relieve  the  circulation  of  this  toxic 
agent  introduced  by  a  long  pulmonary  absorption.  Besides,  the 
heart  is  often  altered,  like  the  kidneys,  in  patients  that  have 
suffered  long  from  an  abdominal  tumor.  It  will,  then,  be  easy  to 
comprehend  the  origin  of  accidents,  which  in  these  cases  succeed 
a  long  anaesthesia,  and  the  pathogeny  of  which  camiot  always  be 
analyzed.  As  to  diseases  of  the  heart,  so  frequent  in  abdominal 
surgery,  wliile  they  demand  particular  attention  in  the  administra- 
tion of  ansesthetics,  are  they  a  formal  indication  against  the  use  of 
chloroform?  The  accidents  most  to  be  feared  proceed  from  the 
reflex  inhibition  of  the  heart  or  respiratory  and  vaso-moter  centers. 
Now  it  is  especially  in  cases  of  organic  alteration  of  the  heart  that 
this  reflex  inhibition  is  to  be  feared.  From  this  comes  the  con- 
clusion that  cliloroform  is  especially  necessary  in  all  important 
operations  on  cardiac  patients  (lesions  of  the  orifices)  and  should 
then  be  given  most  liberally  to  complete  abolition  of  reflex  move- 
ments. 

As  true  contra-indications,  I  cite  fatty  degeneration  of  the  heart, 
confirmed  disease  of  the  kidneys,  general  arterial  atheroma,  ex- 
treme weakness. 

As  this  is  not  the  place  to  teach  the  details  of  ansesthetizing  only 
a  few  recommendations  will  be  given.  In  certain  gynaecological 
operations  the  attention  must  be  redoubled.  When  the  woman  is 
lying  on  the  side,  or  is  held  in  the  genu-pectoral  position,  the 
rispiration  is  bad  and  cliloroforming  is  difficult.  Certain  stages  of 
laparotomy  are  dangerous  from  an  anaesthetic  point  of  view.  Ee- 
moval  of  large  quantities  of  liquid,  ablation  of  large  tumors, 
dragging  on  a  uterine  pedicle  or  on  the  broad  ligaments,  all  may 
act  reflexly  on  the  circulation  and  respiration. 


34  Means  oj  Reunion  and  Hcemostasls. 


CHAPTER  III. 


MEANS   OF  REUNION  AND   H^MOSTASIS. 

Sutures. — Eeuuiou  by  first  iutentiou,  wliicli,  save  in  special 
cases,  has  become  the  rule  in  modern  surgery,  should  never  be 
sought  ■nith  more  care  than  in  gynaecology,  as  it  is  the  condition  of 
perfect  success  in  plastic  operations  and  of  the  safety  of  other 
operations.  I  cannot  cover  all  the  local  conditions  indispensable 
in  order  that  a  wound  should  offer  the  best  conditions  for  reunion; 
the  principles  are,  cleanliness  of  the  surface  of  the  cut,  exact  co- 
aptation (without  fissures  or  dead  spaces),  the  absence  of  traction, 
or  of  exaggerated  pressure.  It  is  necessary  then  to  carefully  pare 
the  raw  surface,  smoothing  it  at  need  with  curved  scissors,  re- 
moving irregularities,  or  exuberant  fatty  portions ;  then  to  place 
the  points  of  suture  in  such  a  manner  as  to  restore  the  tissues  to  a 
coaptation  and  a  pressm-e  which  approaches  the  uonnal  state  as 
nearly  as  possible. 

While  every  gynecologist  ought  to  be  familiar  with  the  ordinary 
surgical  procedures,  it  is  necessary  to  discuss  here  some  points  of 
particular  interest. 

Needles  can  be  used  in  different  ways :  1.  They  can  be  held  in 
the  hand  directly ;  this  practice  is  inconvenient  and  should  only  be 
employed  in  cases  of  necessity.  2.  Needles  are  mounted  on  fixed 
handles  for  traversing  very  resistant  tissues  and  those  difficult  of 
access.  Besides  in  sewing  thi-oi:gh  tissue  of  little  resistance,  but 
rich  in  bloodvessels  (ovarian  pedicles,  broad  ligaments,  etc.),  a 
blunt  needle  is  useful.  3.  Needles  are  usually  employed  with  a 
needle-holder.  Thi-ee  kinds  of  needles  are  used.  Ordinary  surgical 
needles  are  flat  and  slightly  enlarged  near  the  point,  which  has  a 
lance  shape.  From  this  shape  they  have  great  penetrating  power, 
but  also  the  disadvantage  of  producing  small  transverse  wounds, 
which  the  traction  of  the  suture  tends  to  enlarge  (Fig.  6).  Curved 
needles,  or  needles  curved  toward  the  point,  are  especially  used. 
The  flat  Hagedorn  needles  (Fig.  7),  cmwedonthe  edge  and  not  on  the 
face,  have  a  stiU  greater  force  of  penetration,  from  the  beveling  of  the 
point.  They  are  a  great  help  in  aU  plastic  operations.  Needles  of 
different  sizes  are  useful  for  various  purposes.  Very  fine  ones  are 
necessary  for  certain  plastic  operations,  as  vesico-vaginal  fistulse ; 
for  other  operations,  as  in  suture  of  the  abdominal  walls  after  lap- 
artomy,  very  strong  ones  are  employed. 


Means  of  Reunion  and  Hcemostasis. 


35 


Needle  holders  should  fulfill  two  different  requirements,  ac- 
cording as  the  suture  demands  precision  or  as  it  calls  for  much 
force.     In  the  iirst   case   the  most  convenient  is  a  spring-catch 


Fig.  6. — Showing  the  su- 
periority of  flat  needles  over 
ordinary  needles,  aa,  punct- 
ures of  the  ordinary  needle; 
b  b,  enlargement  produced 
by  the  suture;  c  c,  and  d  d, 
illustrating  the  punctures  and 
enlargement  by  the  sutures 
when  the  fiat  needle  is  used. 


Fig.  7. — Dr.  Hagedom's  Needles. 


Fig.  8. — Intestinal  sutures.      I.  Czerny.     2.  Lembert.     3.  Gussenbaur. 

needle  holder,  with  which  the  needle  can  be  used  without  main- 
taining a  pressure  on  the  handle.  When  using  great  force  to  pass 
through  very  thick  and  resisting  tissue,  a  large  needle  is  used  and 
the  pressure  on  the  jaws  of  the  instrument  is  sufficient  to  retain  it. 
It  is  then  preferable  to  have  an  instrument  wdth  free,  strong  handles 
which  form  the  arms  of  a  lever  of  great  power.  With  this  the 
needle  can    be  held  without    fatigue.     The   pushing    force  and 


36  Me(tii><  of  EciiiiioH  and  Ihemostasls. 

pressure  on  the  needle  then  eoiniciling,  a  miisci;hir  consensus 
automatically  employs  for  the  second  a  force  correlative  to  the 
first.  For  sutures  of  the  intestines,  sometimes  necessary  in  lapa- 
rotomy, it  is  better  to  \ise  round  sewing-needles,  as  they  make  a 
smaller  hole.  In  Figure  8  are  given  the  siitures  of  Lemhert,  of 
Czerny  and  of  Gussenhaur,  the  most  used  in  such  cases. 

Materials  for  sutures. — The  older  operators  used  hemp,  silk 
or  linen ;  as  antisepsis  had  not  taught  the  utility  of  perfect  pui'ity  of 
suture  materials,  these  sutures  contained  nests  of  microbes,  and 
suppuration  in  their  track  was  the  rule.  The  introduction  of 
metallic  sutures  by  Sims  and  Bozemaun  was  at  that  time  a  great 
advance,  the  silver  thread  was  so  much  more  aseptic  than  the  others 
that  the  results,  without  doubt,  gave  rise  to  the  enthusiasm  con- 
cerning it.  To-day  they  are  employed  very  generally,  as  they  have 
maiiy  advantages.  But  they  have  also  some  disadvantages :  they 
kink  and  break  easily,  they  cut  more  than  other  sutures,  their  use 
demands  more  time.  Finally,  if  cut  short,  their  sharp  ends 
wound  the  vagina  and  perinseum,  and  if  cut  long  they  are  disposed 
to  dragging.  For  these  reasons  I  seldom  use  them,  replacing  them 
in  most  cases  Avith  aseptic  catgut  or  silk.  Hegar  uses  silver  wire  in 
the  vagina  where  the  permeable  silk  easily  becomes  septic.  But  I 
believe  tlais  can  be  obviated  by  frequent  sublimate  injections  and 
by  iodoform  powder. 

Silk-worm  gut  (made  from  the  silk  glands  of  the  silk-worm)  is  at 
once  impermeable  and  not  absorbed,  Hke  the  silver  wire  ;  it  is  not 
so  easily  kinked  or  broken,  but  is  less  flexible.  It  has  the  stiiiuess 
of  horsehair.  For  the  various  purposes  for  which  metallic  sutures 
have  been  employed,  it  is  prefered  by  some  authorities.  I  have 
found  that  in  a  knot  it  does  not  hold  as  well  as  catgut  or  silk,  and 
that  it  is  as  refractory  to  torsion  as  wire,  so  that  its  sutures  do  not 
afford  perfect  security.  Finally  its  ends  become  very  sharp  on  dr3'- 
ing,  a  fault  in  plastic  operations  on  the  Milva  and  vagina.  It  is, 
however,  a  very  good  suture  in  some  cases.  The  best  silk-worm 
gut  is  of  a  light-red  tint.  It  must  be  soaked  for  a  quarter  of  an 
hour  in  carbolic  or  sublimate  solution  before  using,  or  it  will  have 
an  inconvenient  stiffness. 

The  strongest  silk  is  the  plaited  (and  not  the  twisted).  It  is  ex- 
cellent suture  material  when  it  is  made  aseptic  as  indicated.  It 
can  be  employed  as  a  deep  or  buried  suture  or  even  left  in  the  ab- 
dominal cavity.  Experiments  have  proven  that  it  is  capable  of 
absorption.  However,  there  is  no  doubt  that  it  is  inferior  in  tills 
respect  to  catgut.  In  all  cases  consequently,  when  long  persistence 
of  the  suture  is  not  desired,  I  prefer  to  substitute  catgut.  On  the 
contrary,  in  suture  of  the  intestine,  stomach  or  bladder,  I  use,  by 
preference,  very  fine  silk  tln-ead.  In  certain  i^laces  when  a  long 
line  of  catgut  sutiires  is  used,  the  sustaining  points  of  the  suture 


Means  of  Reunion  and  Hcemostasis,  37 

should  be  of  silk.  But  silk  has  the  disadvantage,  owing  to  its 
porous  nature,  that  must  be  noted,  of  the  possibility  of 
secondary  infection.  Consequently  silk  sutures  and  ligatures,  left 
in  places  where  suppuration  can  occur,  are  often  the  cause  of  obsti- 
nate fistulfe,  which  last  until  the  elimination  of  the  septic  thread. 
It  is  preferable,  then,  to  use  catgut  for  ligatures  and  silk- worm  gut 
for  sutures  in  such  places.  Tliis  precept  has  one  of  its  principal  ap- 
plications in  pyosalpynx  and  pelvic  abscess.  Likewise,  sutures  of 
the  abdommal  walls  m  contact  with  a  dramage  tube  should  not  be  of 
silk  but  of  catgut,  silk- worm  gut,  or  silver  wne. 

There  is  no  suture  or  ligature  in  general  surgery  or  gynsecology 
comparable  to  catgut.  Its  property  of  being  absorbed  m  eight  to 
fifteen  days,  according  to  its  size  and  preparation,  makes  it  of  in- 
estimable value  for  ligatures  left  in  the  abdommal  cavity,  and  for 
sutures  of  the  cervix  and  vaguia  after  plastic  operations,  when  the 
secondary  ablation  of  the  suture  is  so  difficult  and  sometimes  so 
painful.  For  a  long  time  I  have  used  catgut  exclusively  for  all  my 
sutures,  placing  silk  or  silver  wire  at  sustaining  points.  The  tendency 
of  catgut  knots  to  sKp  should  be  remembered,  and,  in  tying,  three 
superposed,  tightly-drawn  knots  should  be  made. 

Different  styles  of  sutures. — The  varieties  of  sutures  are  multiple, 
but  the  tendency  is  now  to  simplification,  and  at  present,  in  every- 
day practice  of  gynsecology,  only  the  follo^ving  are  in  common  use  : 
1.  Interrupted  suture;  2.  Simple  contini;ed  suture;  3.  Contuaued 
suture  in  superposed  planes;  4.  Mixed  or  combined  suture;  5. 
Quilled  suture. 


Fig.  9. — Interrupted  sutures,  a  a,  deep  sutures;  b  b,  suture  passing  under  a  part  of 
the  surface  of  the  wound ;  c  c,  superficial  suture  uniting  the  edges. 

1. — Interrupted  suture. — Whatever  the  extent  of  the  wound,  all  its 
surface  must  be  in  perfect  coaptation,  under  penalty  of  an  accumu- 
lation of  fluids  m  the  angular  spaces,  compromising  the  success  of 
the  suture  by  distention  and  rapid  septic  infection.  To  fulfill  tliis 
important  indication,  in  deep  sutures,  the  needle  passes  under  the 
whole  tliickness  of  the  raw  surface,  or  there  may  sometimes  be  left  in 
the  middle  a  surface  of  one  to  two  centimetres  that  the  suture  crosses 
as  a  bridge  instead   of  passing  under  it  (Fig.  9).     The    needles 


38 


Means  of  licimion  and  Hainostasis. 


employed  for  certain  coaptations  (colpo-perineon-haphy,  etc.)  should 
be  very  long  and  strong.  After  these  deep  sutures  it  is  necessary  to 
use  superficial  ones  ■nith  a  fine  needle  to  secure  exact  union  of  the 
edges  of  the  skin.  To  obtaui  gi-eat  precision  these  superficial  sutm-es 
must  be  placed  very  near  the  edges  of  the  wound.  They  should  be 
placed  last  and  tied  at  once,  while  the  deep  sutures  should  be  placed 
first  and  tied  last.  More  exact  coaptation'  is  thus  secured.  The 
deeper  the  suture,  the  more  distant  from  the  edge  of  the  wound 
should  be  the  point  of  entry.  'WTiererer  it  may  be,  the  traction  of 
a  single  long  suture  unites  the  large  surfaces  like  a  purse-stiing  and 
is  liable  on  excessive  traction  to  cause  puckering.  Hence  arose  the 
idea  of  superposed  bm-ied  sutui-es.  By  a  first  row,  or  first  tier,  of  in- 
terrupted sutm-es  of  catgut,  the  deep  part  of  the  wound  is  closed,  a 
second,  and  even  a  thu-d  row,  closes  the  remaining  sui'face.  This 
procedui'e  is  valuable  in  some  cases,  but  has  the  fault  of  leaving 
knots  at  the  bottom  of  the  wound  which  hinder  coaptation. 


Fig.  10. — I.  Continued  suture:  commencement  of  the  suture ;  1 1,  catgut  thread. 
2.  Continued  suture  almost  finished. 

2. — The  contlmioits  suture  overcomes  this  difficulty.  It  offers  the 
great  advantage  of  being  very  efficacious  while  being  also  very  ex- 
peditious. It  is  especially  valuable  when  one  has  to  make  many 
operations  at  one  time,  for  example,  amputation  of  the  cervix  with 


Means  of  Reunion  and  HcBinostasis.  39 

anterior  colporrhaphy.  Simple  continuous  suture  is  always  suf- 
ficient Avhen  the  surface  is  neither  too  large  or  too  deep ;  it  is  also 
used  for  haemostasis.  We  connnence  by  passing  the  needle  through 
one  angle  of  the  wound  and  by  tying  tln-ee  superposed  knots  on  the 
terminal  extremity  of  the  suture,  of  which  there  should  be  a  short 
end  left.  This  end  is  taken  in  the  jaws  of  the  forceps  (in  the  illus- 
trations this  is  Baumgartner's,  especially  constructed  to  facilitate 
traction  on  the  threads  in  deep  ligature),  an  assistant  holds  this 
and  it  serves  as  a  support  for  the  continuation  of  the  suture  (Fig. 
10).  The  needle  is  then  entered  three  or  four  millimetres  from  the 
edge  of  the  wound,  carried  under  the  whole  surface  and  brought 
out  again  at  an  opposite  point  on  the  other  side  of  the  wound ;  the 
thread  is  moderately  dra^ai  on,  and  given  to  the  assistant  holding 
the  forceps  to  be  kept  tight  while  the  second  stitch  of  the  continuous 
suture  is  made.  He  must  be  careful  not  to  let  go  the  tln-ead  abruptly, 
when  this  second  stitch  is  drawn  through,  but  to  follow  by  maintain- 
ing it  close  to  the  wound,  to  avoid  relaxing  the  preceding  stitch.  It 
is  well,  when  the  middle  is  reached,  to  make  slight  teirsion  on  the 
opposite  angle  of  the  wound  with  the  forceps  to  make  sure  that  the 
edges  are  parallel.  A  useful  precaution  to  avoid  the  constant 
slipping  of  the  thread  in  the  eye  of  the  needle  is  to  fix  it  by  a  single 
knot. 

3. — The  continuous  suture  in  superposed  %ilanes  is  more  complicated. 
If  one  row  of  stitches  is  manifestly  insufficient  to  effect  complete 
coaptation,  the  needle  not  being  able  to  take  up  all  the  raw  surface, 
the  sutures  should  be  made  in  superposed  rows  or  in  tiers.  For 
this,  at  the  point  where  the  wound  shows  an  excessive  width,  in 
place  of  entering  the  needle  outside  the  edge  of  the  wound,  it  should 
be  entered  inside  on  the  raw  surface,  one  or  two  centimetres  if 
necessary,  always  calculating  this  distance  according  to  the  depth 
of  the  surface  of  the  wound  under  which  the  needle  can  be  passed. 
When  this  has  sufficiently  diminished  the  largest  part  of  the  wound, 
recommence  the  insertion  of  the  needle  now  in  the  skin  and  termi- 
nate the  closing  of  the  wound  by  a  superficial  overcasting,  at  first 
direct  then  reversed  (Fig.  11).  Three  rows  may  thus  be  stiperposed. 
It  is  necessary  not  to  tie  too  tightly,  and  not  to  bring  the  points  of 
the  suture  too  near  together.  In  finishing  and  fastening  the  suture 
•by  overcasting  we  find  two  circumstances  :  if  the  terminal  end  of 
the  thread  has  been  brought  near  the  original  extremity,  by  a  second 
complete  row,  the  two  ends  have  only  to  be  tied  together  (three 
knots),  otherwise  the  end  of  the  thread  is  tied  to  the  last  point  of 
the  overcasting,  which  is  stretched  so  as  to  leave  a  sufficiently  long 
loop,  or  the  thread  is  drawn  in  the  eye  of  the  needle  so  that  the 
terminal  end  is  doubled  in  the  last  stitch,  and  to  this  loop  the  end 
is  tied.  If  the  tln-ead  of  the  lower  row  is  cut  by  accident  in  placing 
the  superficial  tier,  or  if  the  thread  is  broken,  a  separate  deep 


40 


Means  oj  lieunioii  and  Htemostusia. 


Fig.  II. — I.  Continued  suture  in  superposed  planes  (one  at  the  angles,  two  in  the 
middle  of  the  wound).     2.  The  same,  with  three  sutuers  in  the  center. 


Fig.  12. — Continued  sutures  in  tiers  in  perineorrhaphy.  I  2  3,  track  of  the  suture; 
a  b,  simple  continued  suture;  c,  sustaining  interupted  sutures;  d,  commencement  of 
the  superposed  sutures. 


Means  of  Reunion  and  Hcemostasis. 


41 


stitch  is  immediately  taken,  at  the  break,  and  the  previous  suture 
continued.  Finally,  I  cannot  recommend  too  highly  the  placing, 
at  points  which  have  to  sustain  strong  traction  (particularly  those 
where  the  direction  of  the  suture  is  changed,  or  where  a  sort  of 
keystone  to  the  structures  exists),  one  or  two  isolated  sutures,  in 
silk  or  in  silver  wire.  These  are  true  supporting  sutures,  which 
prevent  too  great  strain  on  the  catgut  (Fig.  12).  In  perineorrhaphy 
I  use  two,  one  at  each  extremity  of  the  perinseum,  the  anterior 
embracing  the  end  of  the  reconstructed  recto-vaginal  septum,  the 
posterior  uniting  the  extremities  of  the  anal  sphincter.  In  colpo- 
perineorrhaphy,  only  one  is  placed  at  the  edge  of  the  fourchette. 


Fig.  13. — Suture  of  the  abdominal 
walls  after  hysterectomy.  First  stage 
of  the  continud  suture  (peritonseum). 


Fig.  14. — Second   stage  (musculo- 
aponeurotic  plane). 


4. — Mixed  or  comiined  sutures. — It  is  sometimes  useful  to  combine 
the  continuous  and  interrupted  sutures.  As  example  of  these  mixed 
sutures,  I  shall  describe  my  method  of  closing  the  abdominal  wound 
after  laparotomy.  As  soon  as  the  toilet  of  the  peritonaeum  is  com- 
pleted, the  abdominal  wound  is  brought  together  and  held  closed, 
by  an  assistant,  above  a  compress- sponge  spread  over  the  surface 
of  the  intestines  and  intended  to  protect  these  organs  during  the 
suture.     The  peritonseum  is  then  transfixed  at  the  inferior  part  of 


42  Means  nf  Reaiiioii  and  Hcemostasis. 

of  the  wound  by  a  curved  needle  supplied  with  a  long  needleful  of 
medium  catgut.  A  separate  stitch  is  placed  at  this  point,  with  the 
lower  part  of  the  long  needleful  of  catgut.  The  needle  is  always 
kept  on  the  longer  portion,  while  on  the  shorter  end  of  the  initial 
stitch  is  placed  a  pair  of  forceps,  intended  to  make  traction.  The 
operator  then  continues  to  sew  the  peritonaeum  very  quickly  with 
large  stitches  up  to  the  end  of  the  wound  (Fig.  13) ;  before  finishing 
he  withdraws  the  compress-sponge,  then  he  places  on  the  aponeu- 
rosis a  second  row  of  stitches,  a  little  closer  than  the  others,  closing 
the  sheath  of  the  rectus  muscle  if  it  has  been  opened  (Fig.  14).  He 
reaches  thus  the  place  where  he  commenced,  removes  the  forceps 
which  holds  the  slioi-t  end  of  catgut,  and  ties  thet\\"o  ends.  The 
abdomen  is  then  firmly  closed,  there  is  nothing  left  but  to  reunite 
the  edges  of  the  integmnent  and  of  the  subcutaneous  cellular  tissue, 
winch  sometunes  forms  a  mass  of  considerable  thickness.  With  a 
very  large  curved  needle  and  silk  of  a  strength  in  proportion  to  the 
thickness  of  the  parts,  a  series  of  separate  stitches  is  placed  about 
thi-ee  centimetres  apart.  These  sutures  enter  two  to  thi-ee  centimetres 
from  the  edge  of  the  woimd,  pass  directly  through  aU  the  thickness 
of  the  fatty  layer,  close  to  the  aponeurosis  and  emerge  in  reverse 
dii-ection  thi-ough  the  other  hp  of  the  wound.  As  each  row  of  these 
separate  deep  stitches  is  placed  a  forceps  is  fastened  on  each  end. 
The  wound  being  washed  vdth  a  strong  carbohc  solution,  the  edges 
are  brought  together  and  ^\ith  a  very  small  needle  and  fine  eatgiit, 
or  silk-worm  gut,  one  or  two  separate  stitches  of  superficial  sutm-e 
are  taken  in  each  of  the  intervals  between  the  two  deep  sutm-es. 
These  stitches  are  placed  as  near  as  possible  to  the  edges  of  the  ui- 
tegumeut  and  should  ensure  perfect  coaptation.  (I  often  replace 
them  ^^•ith  a  continuous  sutm-e  of  catgiit.)  It  is  not  imtil  they  are 
entnely  placed  and  knotted,  that  the  points  of  the  deep  suture  should 
be  dra\\-n  and  tied  after  ha^"ing  loosened  the  forceps  that  held  the 
ends  temporality  (.Fig.  15).  If  the  abdominal  walls  are  very  rigid 
(in  nuUiparfp)  or  tense,  silk  should  be  used  in  place  of  catgut  for  the 
deep  sutures. 

5. — Quilled  sutures. — Small  rolls  of  iodoform  gauze  should  be 
substituted  for  the  quiUs  or  the  ends  of  bougies  formerly  used. 
Lister's  lead  plates,  \\iththe  large  silver  \\ire  are  thus  advantageouslj' 
replaced.  This  sutiu-e  is  not  employed  now  in  perineorrhaphy,  but 
there  are  exceptional  eases  m  which  it  may  be  useful.  In  the  case 
of  very  large  adherent  abdominal  tumors,  there  exists,  after  then 
ablation,  a  very  large  raw  sm-face  formed  by  the  walls  of  the  ab- 
domen more  or  less  stripped  of  theii-  peiitouieum  by  the  ruptmre  of 
adhesions.  Tliis  large  oozing  surface  gives  lise  to  danger  of  sep- 
tdcsemia.  It  is  useful  then  to  place  at  each  side,  before  closing  the 
abdomen,  a  long  deep  sutm-e,  supported  at  each  end  by  a  roll  of 
iodoform  gauze.     These  exercise  an  eSicient  pressure  on  the  raw 


Means  of  Reunion  and  Hamostasls. 


43 


surfaces,  stop  the  haemorrhage  or  the  serous  oozing,  and  eliminate 
one  of  the  causes  of  early  infection.  These  sutures  ought  to  be  re- 
tained about  iive  or  six  days. 

Htemostasis  may  be  obtained  in  various  ways :  compression  for 
capillary  haemorrhage,  torsion  for  small  arteries,  and  suture  for  the 
surface  of  a  wound,  but  the  two  great  methods  are  ligature  and 
forcipressure.  Isolated  ligatures  of  the  vessels  call  for  no  attention 
as  they  present  nothmg  special. 


Fig.  15. — Suture  of  the  abdominal  walls  after  hysterectomy.     Interrupted  suture  of 
the  subcutaneous  adipose  tissue  and  of  the  integument. 

Ligature  en  masse  offers  great  interest  in  gynecology,  since  with 
its  help  we  control  haemorrhages,  often  formidable,  of  the  pedicles 
of  abdominal  tumors.  This  ligature  is  made,  according  to  circum- 
stances, with  wire,  with  silk  or  catgut  tliread,  or  with  elastic  tubes. 
We  shall  better  study  this  question  in  treating  of  ovariotomy  and 
hysterectomy.  Silk  is  the  most  used  in  ligature  en  masse  of  the 
pedicle,  because  of  the  great  resistance  in  a  small  volume ;  plaited 
and  not  twisted  silk  should  always  be  chosen.  There  is  no  doubt, 
however,  that  when  a  large  quantity  of  thread  has  to  left  in  the  ab- 
domen (as  after  hysterotomies  by  Schrceder's  method),  it  is  a  dis- 
advantage to  use,  in  the  serous  cavity,  material  which  takes  long 


44 


Means  of  Reunion  and  Htemostasis. 


for  absorption  and  of  a  porosity  that  renders  it  liable  to  secondary 
infection.  Thus  since  the  preparation  of  catgut  in  juniper  oil  has 
put  into  our  hands  a  material  superior  to  that  formerly  employed, 
many  gynscologists  do  not  hesitate  to  reject  silk  completely,  sub- 
stituting catgut,  although  it  is  more  difficult  to  tighten  iu  a  ligature. 


Fig.  i6. — l.  Surgeon's  knot  badly  made.  2.  Surgeon's  knot  tied  correctly.  3.  Trans- 
fixion of  a  pedicle  by  a  needle.  4.  Crossing  of  the  two  threads  after  transfixion. 
5.  Bantock's  knot.  6.  Tait's  knot  (StaflTordshire  knot).  7.  Chain  ligature  for  a  larye 
pedicie.     S.  Chain  ligature  tied. 

I  shall  confine  myself  to  the  usual  modes  of  ligature  en  ma^se.  If 
the  portion  to  be  tied  is  relatively  small  and  one  loop  of  the  ligature 
is  sufficient,  it  should  be  passed  around,  drawn  tightly,  and  tied  with 
a  siu-geon's  Imot  (Fig.  16,  1  and  2).  If  the  pedicle  is  large  and  two 
loops  are  necessary,  it  should  be  transfixed  at  the  middle  by  a  needle, 
threaded  with  a  double  tlu-ead  (Fig.  16,  3) ;  the  loop  can  then  be  cut 
so  as  to  have  two  ends,  cross  them  and  luiot  to  the  right  and  left 
(Fig.  16,  4).  'What  is  better,  m  order  to  avoid  two  knots  (the  knots 
are  less  easily  tolerated  than  the  rest  of  the  ligature),  make  the 
Bantockknot  (Fig.  16,  o),  or  Lawson  Tait's  knot,  Staff ordshii-e  knot 
(Fig.  16,  6).  If  the  pedicle  is  laminated  (certain  ovarian  pedicles, 
membranous  adhesions,  or  simply  the  broad  ligaments)  a  sei'ies  of 


Means  of  Reunion  and  Hcemostasis. 


45 


ligatures  should  be  made,  connected  in  such  a  manner  as  to  cause 
no  tear  m  drawing  them  tight  (Fig.  16,  7  and  8).  The  Figures  17, 
18  and  19  show  plainly  the  ordinary  procedures  employed  for  in- 
troducing these  sutures,  and  that  wliieh  Wallich  has  recently  proposed 


Fig.  17. — Chain  ligature. 


to  substitute  for  them.  This  last  approaches  closely  to  those  of  J.  W. 
Long,  (Fig.  20)  with  this  difference,  we  use  a  single  thread  (a  double 
eye  appears  useless)  in  place  of  the  series  of  ordinary  pointed  needles 
used  by  Long.  When  ligature  en  masse  is  made  outside  the  abdomen, 
it  causes  sphacelus  of  the  constricted  tissues.  When  it  is  left,  with 
antiseptic  precautions,  in  the  peritoneal  cavity,  the  ligated  parts  do 
not  slough,  they  preserve  a  minimum  of  vitality  from  the  vessels  of 
the  adhesions  and  those  which  pass  above  the  ligature.  At  the  end 
of  some  time  the  stump  is  sluiveled  and  absorbed.  Catgut  ligatures 
are  quickly  absorbed,while  silk  threads  are  first  infiltrated  with  cells, 
then  encysted,  then  disappear ;  but  it  takes  months  for  this  and  it  is 
possible  for  them  to  play  the  part  of  a  foreign  body,  even  after  the 
lapse  of  some  time.  This  late  infection  can  only  be  explained  by  the 
passage  of  germs  tlu'ough  the  intestines  or  fallopian  tubes,  unless  we 
admit  a  latent  microbism,  rekindling  under  a  bad  local  or  general 
condition.  To  avoid  primary  infection,  when  the  surface  of  the 
section  of  a  pelicle  is  suspected  (salpingitis,  etc.),  it  is  better  to  tie 
with  catgut  or  at  least  to  combine  cauterization  with  ligature  en 
masse.     The  aseptic  eschar  is  rapidly  absorbed. 


46 


Means  of  Reunion  and  Hcenwstasis. 


As  to  elastic  ligature,  whether  maintained  outside  or  left  iu  the 
peritonaeum,  I  shall  here  keep  to  generalities,  referring  for  technical 
details  to  the  chapter  on  hysterectomy,  where  its  principal  appli- 
cation is  found.  To  fasten  the  elastic  band  Olshausen  is  content  to 
tie  the  ends  tmce,  placing  some  stitches  of  silk  to  fasten  the  band  to 
the  pedicle  to  prevent  slipping. 


Fig.  iS.— Chain  ligature  (Wallich). 

Thiersch  passes  the  two  ends  thi"ough  a  lead  rhig,  Avhicli  is  crashed 
on  them.  Hegar  places  on  the  two  stretched  ends,  first  a  ligatm-e  of 
silk,  then  a  second  ligatm-e  for  safety  t,Fig.  21  and  •22).  Various 
kinds  of  apparatus  for  fastening  elastic  ligatures  have  been  proposed 
(since  I  constnicted  the  first)  either  to  facilitate  placing  the  ligatm-e 
or  to  hold  it  in  place.  My  instrument,  the  ligator  (Figs.  23, 12  3;  2-4 
and  25),  is  proposed  solely  to  facilitate  the  placing  of  an  elastic  band 
iu  a  narrow  space,  as  the  pelvic  or  vaginal  ca^"ity.  Its  use  is  very 
simple  and,  its  parts  being  easily  separated,  it  can  be  kept  perfectly 
aseptic. 


Means  of  Reunion  and  Hcemoiitasis, 


47 


Fig.  19.  — Different  stages  of  the  chain  ligature  (Wallich). 

Foreipressiure.  —  The  compression  of  the  vessels  by  the  jaws  of 
a  pedicle  forceps  or  by  a  clamp  is  of  great  service,  as  it  immediately 
arrests  the  blood-flow  by  a  provisional  hsemostasis,  which  becomes 
permanent  in  some  instances.  Thus  in  the  course  of  a  laparotomy 
ligatitig  can  be  avoided  until  toward  the  end  of  the  operation.  In 
plastic  operations  this  procedure  must  not  be  abused  for  the  small 
bits  of  tissue  that  are  crushed  in  the  jaws  of  the  forceps  are  an 
obstacle  to  immediate  reunion.  As  with  ligatures,  forcipressure 
may  be  used  for  smgle  bloodvessels  or  for  the  compression  en  masse 
of  thick  tissues.  It  is  therefore  useful  to  have  at  disposal  various 
patterns  and  sizes,  adapted  to  any  emergency,  from  the  powerful 
pedicle  forceps  of  Billroth  to  the  small  haemostatic  forceps  of  Koeberle. 
Although  forcipressure  is  usually  reserved  for  cases  of  necessity  in 
vaginal  hysterectomy,  some  surgeons  have  proposed  its  use  in  prefer- 
ence to  the  ligatures.  As  many  have  taken  up  this  practice  I  shall 
return  to  its  consideration  in  the  chapter  on  cancer  of  the  uterus. 


48 


Means  of  Reunion  and  Hamustasis. 


Fig.  20. — Long's  chain  sutures  with  a  series  of  needles. 


Fig.  21. — Hegar's  forceps  for  fixing  the  elastic  ligature  while  a  thread  passed 
behind  it  can  be  tied. 


Means  of  Reunion  and  Hmmosta 


49 


Here  it  is  only  sufiScient  to  remark  that  foreipressm-e  to  the  neces- 
sary extent  always  causes  an  incomparably  greater  sloughing  than 
that  succeeding  to  ligature.  It  is  therefore  of  less  value  in  an  anti- 
septic point  of  view. 


Fig.  22. —  Elastic  ligature  fastened  by  a  silk  threrd.    (Ilegar.) 


Fig.  23. — Pozzi's  Ligator  for  applying  elastic  ligature 


Drainage. — It  will  be  sufficient  here  to  take  up  some  general 
principles  and  indicate  the  means  of  fulfilling  them. 

Drainage  of  wounds. — In  the  superposed  sutures  of  the  abdominal 
walls  after  laparotomy  it  is  generally  iimiecessary  to  place  a  drainage 
tube  between  the  layers.  But  this  may  become  necessary  if  the  cut 
surface  has  come  into  contact  with  septic  material,  pus  for  examj)le. 
Then,  in  spite  of  the  most  careful  cleaning,  a  serous  or  sero-puru- 
lent  oozing  may  compromise  primary  reunion,  unless  the  fluid  is 
promptly  evacuated  by  drainage.  In  such  cases  a  small  dramage 
tube  is  placed  between  the  sutures  uniting  the  aponeuroses  and  those 
uniting  skin  and  cellular  tissue.  This  tube  is  generally  divided  into 
several  segments  and  each  is  prevented  from  slipping  into  the 
wound  by  transfixing  the  external  extremity  with  a  safety  pin.  The 
best  drainage  tubes  are  of  thick  rubber,  as  they  can  be  curved  at 
need,  and  on  account  of  their  thickness,  preserve  their  calibre  when 
bent 


50 


Meiuis  of  lieuitlon  (Did   Htemustasis. 


Fig.  24. — Application  of  the  elastic  ligature  with  Poz?i  s  li^itor.  i.  First  stage  ;  The 
lower  end  of  the  elastic  ligature  is  held  in  the  fork  of  the  handle;  the  ligature  passing 
under  the  uplifted  pedal  is  engaged  in  the  head  of  the  instrument  by  pressure.  2.  Second 
stage :  The  ligature  has  been  passed  twice  around  the  pedicle;  then  it  is  again  engaged 
in  the  head  of  the  instrument  Isy  pressure. 

Draina(/e  of  the  peritoiucum. — The  fear  of  accuiimlatiou  of  liquid 
in  the  peritonfeum  led,  in  the  early  times  of  laparotomy,  to  the 
practice  of  preventive  periton-pnl  drainage.  In  1872  Sims  recom- 
mended systematic  cbainage  iu  every  ovariotomy.  This  extravagance 
had,  at  least,  the  merit  of  showing  the  harmlessness  of  drainage 
when  surrounded  hy  proper  precautions.  In  fact,  it  is  well  to  know 
that  at  the  end  of  a  few^  hours  the  tube  is  shut  off  by  the  formation 


Means  of  lieumon  and  Hfemostasis. 


51 


of  pseudo  membranes  which  surround  and  isolate  it.  It  is  only  when 
there  is  persistent  oozing  that  a  cavity  remains  at  its  extremity  in 
which  fluid  accumulates.  A  new  element  now  simplifies  the  problem, 
that  is  the  knowledge  of  the  great  power  the  peritonaeum  possesses 
for  resorption,  when  this  property  has  not  been  destroyed  by  exten- 
sive tears,  or  by  long  exposure  to  air  and  paralysis  of  the  intestine. 
From  this  it  results  that  in  simple  laparotomy,  a  very  great  quantity 
of  liquid,  blood  or  serum,  is  rapidly  absorbed  without  danger  to  the 
patient.  The  difficulty  is  to  judge  if  it  will  take  place,  for  if  it  does 
not,  there  are  strong  probabilities  of  septicaemia.  In  a  preceding 
note  it  is  said  that  irrigation  of  the  peritonaeum  temporarily  para- 
lyzes the  absorbent  power  of  the  serosa. 


Fig.  25. — Application  of  the  elastic  ligature  with  Pozzi's  ligator.  I.  Third  stage:  The 
ligature  is  drawn  under  the  pedal  and  fixed  by  lowering  this.  3.  Fourth  stage :  The 
inferior  end  is  detatched  from  the  fork ;  the  head  of  the  instrument  is  detatched  and 
remains  in  place.     (To  the  left  is  a  chain  suture  of  the  broad  ligament.) 


52  Means  of  Reunion  and  Hccmostasis. 

Supposing  that  the  toilet  of  the  peritonseum  has  been  made  with 
compress  sponges,  it  only  remains  in  establishing  the  indication  for 
drainage  to  consider,  not  what  remains  in  the  abdomen,  but  what 
may  be  effused  and  remain.  The  elements  of  appreciation  are  so 
many  that  it  is  difficult  to  establish  absolute  rules,  each  surgeon 
nmst  be  his  own  judge  in  the  individual  case.  However,  the  follow- 
ing may  be  formulated  as  the  principle  indications  for  di-ainage : 

1.  The  fear  of  abundant  oozing  of  blood  or  serum,  after  closing  the 
abdominal  walls,  in  consequence  of  special  anatomical  or  clinical 
conditions,  the  absorbent  power  of  the  peritona;um  not  being  intact. 

2.  Existence  in  the  peritonajal  cavity  of  a  septic  sm-face  capable 
of  furnishing  a  fluid  exudate,  the  resorption  of  which  would  be  dan- 
gerous— existence  of  lesions  of  peritonitis.  3.  Extensive  denudation 
of  the  peritonaeum,  acting :  (a)  as  a  source  of  persistant  oozing ;  (b) 
by  loss  of  the  normal  power  of  absorj)tion.  4.  Long  duration  of 
the  operation  and  laborious  manoeuvres  compromising  the  tonicity 
of  the  intestine  and  the  vitality  of  the  peritoufeum. 

Vaginal  Drainage. — Douglas'  cul-de-sac  being  the  most  dependent 
point  of  the  pelvic  cavity,  it  is  natural  to  take  it  as  the  point  of 
departure  for  the  issue  of  liquids.  Besides,  there  is  the  advantage 
of  not  weakening  the  abdominal  wall  and  favoring  a  future  hernia 
by  retarding  primary  union  at  one  point.  The  only  objections  to 
vaginal  drainage  is  the  richness  of  the  vaginal  canal  in  micro- 
organisms and  the  difficulty  of  perfect  asepsis.  I  will  omit  the 
inefficient  or  complicated  processes  and  confine  myself  to  those 
that  are  best.  One  of  these  is  the  introduction  of  a  tube  in  the  form 
of  a  cross  (Fig.  26).  After  laparotomy  this  tube  can  be  introduced 
into  the  posterior  cul-de-sac  tln-ough  an  mcision,  or  directly  by 
puncture  ■with  a  large  trocar.  The  transverse  branch  of  the  tube 
keeps  it  in  place  without  preventing  its  withdrawal  by  forcible 
traction.  The  lower  extremity  is  always  ■s\Tapped  in  iodoform 
gauze.  This  drainage-tube  is  left  in  place  from  six  to  eight  days, 
or  more,  on  special  indication.  A  disagreeable  sensation,  a  sense 
of  weight  in  the  lower  part  of  the  abdomen,  indicates  that  it  is  not 
well  tolerated.  It  is  not  prudent  to  make  any  injection  tlu'ough  the 
tube  nor  in  the  vagina  while  it  remams  in  place ;  the  liquids  are 
absorbed  by  iodoform  gauze  softly  packed  in  the  vagina. 

Drainage  of  the  abdommal  ca^^ty  has  been  made  chieflly  ^^ith 
glass  tubes.  It  is  better  to  have  them  made  \vith  openings  in  then- 
lower  end  only.  Thej'  are  mtroduced  into  Douglas'  cul-de-sac  and 
the  upper  external  extremity  of  the  tube  is  enveloped  in  an  absorbent 
dressing.  Lawson  Tait  uses  a  special  instrument  to  evacuate  the 
fluids  from  the  tube.  Since  1867,  Kceberle  has  filled  the  canula 
\vith  carbohzed  absorbent  cotton,  destined  to  absorb  them.  Hegar 
•  in  adopting  tliis  procedure  improved  it  by  taking  advantage  of  the 
capillary  attraction  of  the  substance  contamed  in  the  tube,  which 


Means  of  Reunion  and  Hcemostasis. 


53 


is  frequently  renewed.  Hegar  has  now  abandoned  this  for  capillary 
drainage  with  gauze  alone.  Thus  it  is  that  capillary  drainage  has 
long  been  the  auxiliary  of  drainage  of  the  abdomen  by  the  tube. 


Fig.  26. — I.  Rubber  drainage-tube  in  form  of  a  cross.     2.  Method  of 
seizing  with  the  forceps  for  introduction  into  a  cavity. 

The  indications  for  simple  capillary  drainage  of  the  peritonaeum, 
independently  of  its  combination  with  tamponing  (of  which  I  shall 
treat  later),  are,  I  believe,  very  limited.  I  employ  it  only  after 
vaginal  hysterectomy.  Instead  of  introducing  one  or  two  tubes  into 
the  opening  in  the  peritonaeum,  or  of  leavmg  it  gaping,  after  the 
method  of  some  surgeons,  I  prefer,  after  havmg  reduced  it  to  a  small 
opening  by  two  lateral  sutures,  to  push  into  ii,  to  the  depth  of  about 
an  inch,  a  strip  of  iodoform  gauze  doubled  at  its  upper  end,  the 
ends  being  rolled  up  in  the  vagina.  At  the  end  of  a  variable  time, 
according  to  the  amount  of  oozing,  the  other  strips  of  iodoform 
gauze,  which  complete  the  intra- vaginal  dressing,  are  renewed,  the 
one  placed  in  Douglas'  cul-de-sac  remaining  untouched,  as  it  main- 


54  Means  of  Reunion  and  Heemostasis. 

tains  the  di'aiuage  opening.  At  the  end  of  six  to  eight  days  this  too 
is  removed. 

Antiseptic  tamponnement  of  the  peritonaiun. — It  is  certainly  a  bold 
idea  to  pack  a  part  of  the  peritouseal  ca%"ity  with  an  antiseptic 
tampon  in  such  a  way  as  to  isolate  the  portion  tamponed  from  the 
rest  of  the  peritonaeum.  This  result  is  produced  during  the  first  few 
hours  by  the  bulwark  formed  by  tamponing,  ultimately  by  adhesions 
that  it  produces  at  its  periphery.  A  similar  audacity,  inspired  by 
its  success,  is  the  substitution  of  tamponing  for  drainage.  Antiseptic 
tamponnement  of  the  peritonaeum  was  suggested  by  M.  Mikuhcz. 
Mikulicz  advises,  first,  plaemg  at  the  bottom  of  the  cavity  to  be 
tamponed,  a  sort  of  pm-se  made  by  pushing  in  a  bit  of  iodofonn 
gauze  (20-100).  In  the  middle  of  this  gauze  is  fixed  a  double  thi-ead 
of  antiseptic  silk  to  aid  in  withdrawing  it.  Once  the  pm-se  is  in 
place,  two  to  five  long  strips  of  iodoform  gauze  are  introduced, 
disposed  in  such  a  way  as  to  cover  aU  the  surface  of  the  cavity. 
Then-  superior  ends  pass  thi-ough  the  neck  of  the  pui'se  and  issue 
■with  it  from  the  inferior  extremity  of  the  abdominal  wound  (Fig.  27). 
This  procedm-e  can  be  suuphfied,  in  smaU  spaces,  by  packing  the 
strips  of  gauze  directly  into  the  depths  of  the  cavity,  but  care  must 
be  taken  to  scrape  the  edges  of  the  gauze,  so  that  no  filaments  can 
be  detached.  A  useful  precaution  consists  in  introducing,  at  the  same 
time,  a  large  drainage  tube  m  the  center  of  the  tampoimement,  to 
avoid  retention  of  hquid  too  thick  to  filter  thi-ough  the  gauze.  I  wish 
to  recommend  also  that  all  excess  of  iodoform  be  avoided  for  fear  of 
toxic  effects. 

What  length  of  time  should  the  tampon  be  left  ?  Mikuhcz  recom- 
mends withdrawal  of  the  inner  strips  after  forty-eight  hours,  and  of 
the  sac  itself  two  or  thi-ee  days  later.  The  amount  of  oozing  and 
the  state  of  the  tamponed  parts  should  guide  us.  In  all  cases  it  is 
necessary  to  remove  the  sac  before  the  fifth  day,  allowing  time  for 
the  peripheral  adhesions  to  consohdate.  There  is  no  difficulty  in 
removal  if  a  mark  is  placed  on  the  gauze  rolls  to  distinguish  the 
superficial  fi-om  the  deep.  The  external  tampons  must  be  changed, 
however,  as  often  as  necessary,  that  is  about  thi-ee  times  a  day. 
They  rapidly  imbibe  the  sanguinoleut  serum  oozing  from  the  bottom 
of  the  wound  and  transmitted  by  capillary  attraction  from  the  deep 
part  of  the  tamponnement. 

It  is  as  impossible  to  give  rales  for  the  cases  that  need  tamponne- 
ment as  it  is  for  drainage.  Much  is  left  to  the  tact  of  the  operator. 
Tampoimement  should  eertauily  be  the  exception,  an  ultima  ratio, 
either  against  parenchymatous  hi^mon-hage  (hemostatic  tamponne- 
ment") ,  or  against  infection  ( antiseptic  protective  tamponnement) .  In 
the  latter  case  two  different  circumstances  present  themselves :  (a), 
the  infection  of  a  part  of  the  wound  existing  at  the  time  of  operation 
ation  and  not  controUable  by  ii-rigation,  or  the  presence  of  a  por- 


Means  of  Reunion  and  Hcemostasis. 


55 


tionof  infected  tissue  that  it  is  dangerous  to  remove  ;  (b).  infection 
is  to  be  feared  after  the  occlusion  of  the  abdominal  wound,  from 
the  slouglnng  out  of  a  suture  made  ujider  bad  conditions,  or  from 
perforation  of  an  organ  compromised  before  or  during  the  operation. 
In  such  circumstances  I  have  had  recourse  to  antiseptic  tamponne- 
ment  of  the  peritonseum. 


Fig.  27.- 


-Tamponnement  of  the  peritonaeum  {after  hysterectomy),    a  a,  sac  of  iodoform 
gauze;   b,  silk  thread;   c  c,  strips  of  gauze. 


Intrauterine  drainage. — Capilary  dramage  of  the  uterus  with  iodo- 
form gauze  has  been  employed  as  a  means  of  antisepsis  in  uterine 
catarrh.  A  fine  strip  of  iodoform  gauze  is  generally  used  by  pushing 
it  up  into  the  uterus  mth  a  sound.  At  the  end  of  twenty-four  hours 
this  is  renewed  and  the  ca\'ity  will  then  be  dilated  enough  to  make 
its  introduction  much  more  easy.  Drainage  with  a  rubber  tube, 
with  holes  in  the  portion  contamed  m  the  uterus,  has  beeia  used,  but 
the  idea  of  evacuation  of  mucus  by  this  means  is  an  illusion.  It  is 
a  mistaken  procedure  and  it  may  even  cause  infection  of  the  uterus 
in  place  of  removing  it.  The  situation  is  different  when  the  uterus 
is  sufficiently  dilated  to  allow  the  introduction  of  the  drainage-tube 
in  the  shape  of  a  cross.  Tins  is  preferable  to  the  metallic  di-ainage- 
tube  that  has  been  recommended.  The  drainage-tube  of  two  crossed 
pieces  of  rubber,  renders  great  service  Avhen  there  exists  in  the  dilated 


56  Means  of  Rcun'wn  and  Hceriwstasis. 

iiteiiiii  a  permanent  source  of  infection,  as,  for  example,  sloughing 
fibroid  or  debris  of  foetal  membranes.  At  need,  this  drainage  may 
be  made  the  first  stage  of  a  eontmuous  irrigation  and  in  all  cases  it 
facilitates  the  exit  of  the  secreted  fluids  and  the  administration  of 
intrauterine  injections. 

Continuous  irrigation. — As  a  preliminary  the  cruciform  drainage- 
tube  is  introduced  into  the  uteiine  canity.  The  uteiine  cavity  being 
dilated  m  cases  where  its  use  is  necessary,  this  offers  no  difficulty. 
Fu-st,  two  or  three  litres  of  an  antiseptic  solution  (carbolic  acid 
30-1000  or  sublimate  1-2000)  are  quickly  passed  through  the  uterus. 
Irrigation  is  continued  until  the  water  issues  clear,  this  is  followed  by 
continuous  in-igatiou,  di'op  by  di-op,  bj'  the  aid  of  a  special  apparatus 
or  simply  by  regulating  the  flow  of  water  by  the  ordinary  stop-cock. 
For  this  a  weak  solution  (10-1000  carbolic  acid  or  1-5000  sublimate) 
is  employed.  The  temperatm^e  of  the  injection  should  be  33^  C.  to 
38°  C.  To  avoid  excoriation  the  external  genital  organs  may  be 
smeared  mth  vaseline. 

Antiseptic  tamjwnnement  of  uterine  cavity. — Long  strips  of  iodoform 
gauze  are  pushed  carefully  into  the  utems  with  a  blunt  iustrnment 
or  a  long  curs'ed  forceps,  and  packed  up  toward  the  fundus  little  by 
little.  As  an  antiseptic  measm-e  the  gauze  can  be  left  in  place  three 
to  six  days.  Intrauterine  tamponnement  may  also  be  used  as  a 
hfemostatic.  Exceptionally  a  little  perchloride  of  iron  may  be  added 
after  curetting  for  uterine  cancer,  or  after  enucleation  of  a  fibroid. 

Tamponnement  of  the  vagina. — The  application  of  a  tampon  must 
not  be  confounded  with  tamponnement.  That  the  last  term  may  be 
applicable  the  whole  extent  of  the  vaguial  canal  must  be  filled  with 
a  continuous  column  of  a  more  or  less  elastic  substance,  chai-pie, 
cotton,  gauze  or  wool,  rendered  aseptic  and  antiseptic  by  proper 
preparation.  In  these  may  be  iucoi-porated  various  medicinal  agents 
which  add  their  special  action  to  the  mechanical  effect  of  the  tam- 
ponnement. They  are  utilized  for  two  purposes  :  1.  Hemostatic; 
2.  Antiphlogistic. 

1.  Hcemostatic  tamponnement. — This  is  never  a  measure  of  choice, 
but  always  one  of  necessity — when  a  profuse  metrorrhagia  demands 
prompt  attention  to  avert  a  fatal  result.  It  would  be  preferable,  of 
course,  in  each  individual  case  to  direct  treatment  to  the  cause,  but 
as  this  is  not  always  possible,  we  have  recom'se,  to  gam  time,  to  a 
vaginal  tamponnement,  packing  against  the  cervix  a  substance  not 
easily  pemieated,  that  compels  the  blood  to  coagulate  in  the  uterus. 
It  must  be  vmderstood  that  this  is  an  expedient  and  not  a  treatment ; 
it  cannot  be  prolonged  without  serious  danger,  resulting  either  from 
the  cause  of  the  hnemorrhage,  or  fi-om  the  reaction  caused  by  the 
pressure  of  the  foreign  body  which  fills  the  vagina.  Tamponnement 
should  be  applied  as  follows  :  The  rectum  and  bladder  are  emptied. 
The  most  favorable  position  to  expose  the  vagina,  without  tiring 


Means  of  Reunion  and  Hcemostasis.  57 

the  patient  too  much,  is  Sims'  position.  The  speculum  pulls  back 
the  posterior  vaginal  wall  and  an  irrigation  with  carbolized  water 
10-1000,  clears  the  vagina  of  clots  and  accumulated  blood.  It  only 
remains  to  fill  the  cavity.  For  this  I  recommend  the  preparation 
of  a  series  of  small  tampons  of  absorbent  cotton,  dipped,  some  in  a„ 
concentrated  solution  of  alum,  the  greater  number  in  a  weak  carbolic 
solution  which  has  served  for  irrigation.  These  are  squeezed  as  dry 
as  possible  at  the  moment  of  using  and  then  form  disks  the  diameter 
of  a  silver  dollar  and  double  or  triple  the  thickness.  With  a  long 
forceps  five  or  six  of  the  alum  disks  are  quickly  disposed  around  the 
cervix  in  the  cul-de-sac  and  at  the  os  uteri.  As  soon  as  these  are 
placed  the  carbolized  disks  are  used  to  complete  the  tamponnement. 
A  large  quantity  of  the  cotton  disks  are  necessary,  although  they 
should  not  be  packed  with  much  force,  but  only  superposed  so  as  to 
form  a  homogeneous  whole.  In  proportion  as  the  vagina  is  filled 
the  speculum  should  be  withdrawn  and  wholly  removed  a  little 
before  completing  the  packing.  It  is  sometimes  necessary  to  cathe- 
terize  these  patients  on  account  of  the  pressure  on  the  neck  of  the 
bladder.  The  cotton  should  not  be  left  in  place  more  than  twenty- 
four  hours ;  after  having  removed  it  a  copious  hot  douche  is  given. 
2.  Antiphlogistic  tamponnement  lifts  the  uterus  up  mechanically, 
relieving  the  ligaments  from  its  weight,  diminishing  the  venous  stasis 
due  to  the  descent  of  the  organ,  and  limiting  the  access  of  the  arterial 
blood  by  excentrio  compression.  Thus  it  combats  congestion,  in- 
flammation, putting  the  tissues  in  a  state  favorable  to  the  resorption 
of  exudates  and  to  the  cessation  of  pathological  reflexes.  The 
position  of  the  patient  most  favorable  to  its  application  is  the  genu- 
pectoral.  There  should  be  at  least :  1.  Small  tampons  of  absorbent 
cotton  prepared  in  antiseptic  glycerine  and  squeezed  out:  2.  Fine 
surgeon's  wool,  purified  by  the  sterilizing  oven,  washed  in  carbolic 
solution,  10-1000,  then  well  dried,  this  substance  being  employed  on 
account  of  its  great  elasticity.  Tamponnement  made  with  absorb- 
ent cotton  in  its  whole  extent  would  be  too  compact.  The  first 
tampons  are  placed  in  the  posterior  cul-de-sac,  then  all  around  the 
cervix,  which  should  be  thus  immobilized.  The  remainder  of  the 
vagina  is  then  fiUed  with  the  wool.  It  is  better  to  keep  the  patient 
in  bed  for  one  or  two  days  after  the  first  tamponnement.  After  this 
she  may  be  allowed  on  her  feet.  If  erythema  follows  the  use  of 
dry  packing,  a  dressing  coated  with  vaseUne  may  be  substituted. 
The  tamponnement  is  renewed  every  two  or  three  days,  and  in 
order  to  produce  its  full  effects  it  must  be  persistently  employed  for 
some  weeks.  If  the  cotton  or  wool  be  impregnated  with  medicinal 
substances,  such  as  the  glycerole  of  tannin,  etc.,  it  will  act  as  a 
topical  application  to  aU  the  vaginal  mucosa.  But  strictly  speaking, 
when  it  is  made  for  this  purpose  it  is  no  longer  a  tamponnement, 
but  an  aggregation  of  tampons. 


58  Gyiuecologiad  Exaininations. 


CHAPTER  IV. 


GYNECOLOGICAL    EXAMINATIONS. 

Position  of  the  patient — By  examination  in  the  upright 
position  only  very  Umited  knowledge  can  be  gained.  Exammatiou 
thus  practiced  affords  useful  information,  however,  in  displacements 
of  the  genital  organs  and  abdominal  tumors.  The  physician  kneels 
on  the  left  knee  so  that  his  right  thigh,  semi-flexed,  serves  as  a  sup- 
port for  his  elbow  of  the  same  side.  But  the  upright  position  is 
unfavorable  for  complete  examination,  and  only  deserves  mention. 
The  principal  positions  are :  the  dorsal,  the  lateral,  and  the  genu- 
pectoral. 

The  simple  dorsal. — It  is  sufficient  for  a  cursory  abdominal  and 
digital  examination,  to  place  the  woman  on  her  back  the  head  resting 
on  a  cusliion,  the  thighs  slightly  flexed  and  abducted.  This  is  the 
ordinary  position  for  examination  in  bed.  It  has  the  disadvantage 
of  allomng  only  slight  relaxation  of  the  abdominal  muscles,  ob- 
structmg  xmlpation,  and  is  wholly  unsuitable  for  the  use  of  the 
speculum. 

Modified  doral  lithotomy  j)osition. — This  both  procures  relaxation 
of  the  abdominal  walls  and  allows  easy  introduction  of  the  linger 
and  speculum.  It  is  used  by  prefference  for  complete  examination. 
The  nates  are  brought  to  the  edge  of  the  bed  or  table,  the  trunk  and 
head  are  moderately  elevated,  the  thighs  are  flexed  on  the  pelvis 
and  the  legs  on  the  tliighs  and  maintained  in  this  position  by  the 
assistants  or  by  the  use  of  special  apparatus. 

Dorso-sacral  position . — Tliis  is  the  most  convenient  for  aU  opera- 
tions on  the  external  genitals,  or  on  the  vagina  and  uterus  through 
the  natural  passages.  It  brings  all  the  parts  within  easy  access. 
The  patient  is  placed  at  the  edge  of  a  bed  or  table,  the  head  sHghtly 
elevated  by  a  cushion,  the  trunk  is  horizontal  and  the  peMs  is 
elevated  and  flexed  on  the  vertebral  column  in  such  a  way  as  to 
present  marked  obliquity  from  above  do^nrward  and  from  before 
backward.  The  legs  are  flexed  and  carried  toward  the  abdomen  by 
the  assistant,  who  holds  the  limbs  so  flexed  as  to  keep  one  hand 
free  to  help  the  operator.  When  there  are  no  assistants  at  hand, 
Fritsch's  apparatus  and  speculum  can  be  utiUzed.  There  are 
several  instruments  of  this  type  for  separation  of  the  thighs  and 
flexion  of  the  legs.  A  very  useful  modification  of  this  position  con- 
sists in  great  elevation  of  the  pelvis  above  the  rest  of  the  trunk. 


Gyncecological  Examinations.  59 

This  greater  elevation  of  the  pelvis  causes  the  intestines  to  fall 
toward  the  diaphragm  and  permits  a  more  easy  exploration  of  the 
pelvic  organs.  This  position  is  of  great  help  to  the  operator  by  re- 
lieving pelvic  pressure  in  examinations,  especially  of  small  tumors 
of  the  uterine  appendages.  To  facilitate  exploration  and  to  render 
the  pelvic  organs  more  accessible  during  an  operation  it  is  equally 
useful  to  have  an  assistant  lift  up  the  uterus  Avith  two  fingers  in  the 
vagina,  or  to  employ,  for  the  same  purpose,  an  inflated  air-pessary. 

Sims'  position. — In  gynecology  only  the  modified  lateral  or  ab- 
dominal lateral,  better  known  as  Sims'  position,  is  in  general  use. 
It  is  adapted  for  examination  with  the  speculum  of  the  same  author. 
(The  weight  of  the  viscera  falling  forward,  the  air  then  easily  sepa- 
rates the  vaginal  walls.)  This  position  is  of  great  service  in  various 
cases.  Finally,  it  caters  to  the  modesty  of  some  women.  The 
woman  should  lie  on  the  side  at  the  edge  of  a  bed  or  table,  the  legs 
flexed  on  the  thighs  at  a  right  angle.  The  lower  limbs  are  supported 
by  an  assistant  or  by  a  sidepiece  to  the  table  The  trunk,  in  place 
of  resting  on  the  side,  undergoes  torsion  so  that  the  face  is  turned 
toward  the  table ;  to  facilitate  this  the  corresponding  arm  is  dis- 
engaged from  under  the  trunk  and  embraces  the  table. 

Genu-pectoral  position. — Women  scarcely  ever  submit  to  this 
position,  and  it  is  only  exceptionally  necessary  in  cases  of  displace- 
ment. By  lowering  the  viscera  it  lowers  the  abdominal  pressure, 
allows  the  uterus  to  incline  forward  and  balloons  the  vagina  by 
allowing  the  air  to  rush  in  as  soon  as  the  walls  are  separated.  The 
woman  is  put  on  all-fours,  on  knees  and  elbows,  the  nates  project- 
ing a  little  over  the  edge  of  the  table.  According  to  the  corpulence 
of  the  woman  she  may  rest  on  the  elbows  or  chest.  This  position 
is  cramped  and  becomes  painful  if  long  maintained. 

Simple  abdominal  palpation — The  patient  is  placed  in  the 
dorsal  position,  with  the  knees  slightly  flexed.  She  is  told  to  breathe 
without  effort,  mouth  open,  and  to  relax  the  muscles.  Care  is  taken 
to  have  the  bladder  and  rectum  empty.  The  operator's  two  hands 
are  simultaneously  employed.  They  must  not  be  cold,  for  fear  of 
reflex  contractions.  At  first,  proceed  very  gently  and  then,  after 
having  accustomed  the  abdomen,  so  to  speak,  to  manipulations, 
employ  more  force  and  sink  the  fingers  into  the  abdominal  walls 
for  a  deeper  exploration.  It  has  even  been  claimed  that  a  certain 
amount  of  massage  disarms  the  reflexes.  Proceed  methodically, 
palpate  first  the  hypogastric  region,  then  the  ihac  fossae-  in  such  a 
way  as  to  determine  the  changes  in  the  volume  or  situation  of  the 
internal  genital  organs.  Finally  turn  to  the  flanks,  to  the  epi- 
gastrium and  to  the  hypochondriac  regions. 

The  normal  consistence  of  the  abdomen  presents  variations  that 
it  is  necessary  to  take  into  account.  The  age  of  the  patient,  the 
absence  of  anterior  fat,  multiparity,  the  thinness  or  the  obesity,  the 


60  Gyn (ecological  Examinations. 

distention  of  the  stomach  and  intestines  by  gas  in  dyspeptics,  etc., 
are  important  conditions  wliicli  introduce  sources  of  error.  If  care 
has  been  taken  to  empty  the  bladder  and  rectum,  this  will  guard 
against  mistaking  their  contents  for  a  tumor.  The  peculiar  con- 
sistence of  fecal  material  contained  in  the  rectum,  or  tlie  cnecum, 
or  the  sigmoid  flexure,  their  position  in  the  region  of  the  flanks, 
possibility  of  making  a  persistent  impression,  are  characteristic 
enough.  It  often  happens  that  in  spite  of  energetic  purgation 
scybala  may  accumulate,  especially  if  there  exists  a  mechanical 
cause  for  constipation. 

An  enormously  distended  bladder  has  been  taken  for  a  cyst.  Its 
unusual  proportions  may  proceed  fi'om  compression  of  the  neck,  or 
fi'om  an  affection  of  the  nervous  system  which  blunts  the  sensibOity. 
I  was  once  called  to  an  asylum  to  puncture  an  ovarian  cyst  which 
was  only  a  distended  bladder  in  a  general  paralytic.  Finally  it  is 
necessary  to  know  that  catheterism  quickly  done  does  not  always 
completely  empty  the  bladder.  In  some  cases  the  bladder  is  bilobed 
from  being  compressed  between  a  pelvic  tumor  and  the  pubes. 

The  rectus  muscles  have  given  rise  to  the  sensation  of  a  tumor  by 
the  rigiditj'  of  their  contracted  mass  and  the  distinctness  of  their 
border.  This  occurs  especially  when  there  is  a  certain  separation 
at  the  linea  alba.  It  also  appears  that  these  muscles  can  contract 
partially  between  two  aponeurotic  intersections  thus  adding  to  the 
difficulties.  Meteorism  may  simulate  a  tumor  or  even  pregnancy. 
Percussion  will  be  of  service,  but  ■s\'iU  not  remove  all  doubts. 

Masses  of  fatty  tissue,  especially  in  the  region  of  the  flanks, 
sometimes  give  rise  to  doubt.  I  will  remark  on  this  subject  that  I 
have  often  observed  an  extra  amount  of  fat  in  the  hypogastrium  of 
women  affected  with  a  chronic  disease  of  the  genital  apparatus, 
and  even  among  dyspeptics  one  sees  an  accumulation  of  fat  in  the 
epigastrium. 

Finally,  there  are  some  women  that  have  so  gi-eat  an  hyperses- 
thesia  or  so  little  courage  that  they  become  rigid  on  the  slightest 
touch.  In  these  cases  and  especially  if  an  important  decision  is 
concerned,  it  is  necessary  to  aniesthetize.  Thus  a  knowledge  in- 
comparably more  precise  may  be  obtained,  especially  when  ab- 
dominal palpation  is  combined  with  vaginal  touch  (bimanual  exami- 
nation). Save  in  exceptional  cases  of  thinness  and  flaceidity  one 
can  scarcely  accomplish  palpation  of  the  tubes  and  ovaries  ^vithout 
anesthesia.  The  relations  of  swellings  or  tumors  cannot  be  made 
out  with  any  precision  without  it.  Often,  for  example,  a  tumor  which 
is  apparently  attached  to  the  uterus  when  the  patient  is  awake, 
separates  itself  very  clearly  when  she  is  imder  anaesthesia.  Finally, 
a  tumor  which  appears  hard  may  become  manifestly  fluctuant  under 
chloroform. 

Vacfmal  touch. — The  index  finger,  coated  with  an  antiseptic  oily 


Gynrecological  Examinations.  61 

substance  (borated  vaseline,  carbolized  oil),  glides  over  the  fourcliette 
into  the  vagina.  Many  gynaecologists  use  an  antiseptic  injection 
after  the  examination.  To  my  mind  it  is  no  less  necessary  before. 
The  finger,  which  brings  with  it  a  mass  of  germs,  may  inoculate  the 
patient  by  abrading,  even  very  slightly,  the  cervix.  In  general,  the 
examination  should  be,  so  to  speak,  sandwiched  between  two  anti- 
septic injections.  The  index  finger  is  the  most  convenient.  The 
thumb  remains  extended  and  is  placed  obliquely  toward  one  or  the 
other  of  the  genito- crural  folds,  always  avoiding  the  median  line. 
The  other  three  fingers,  semi-flexed,  depress  the  perinseum.  The 
finger  follows  the  posterior  or  lateral  part  of  the  vagina  to  arrive  at 
the  cervix.  When  this  is  not  found  directly  in  the  axis,  a  movement 
of  rotation  is  made  from  behind  forward  and  fi-om  before  backward, 
seeking  it  until  the  external  orifice  is  felt.  Account  is  then  taken 
successively  of  the  direction  of  the  cervix,  its  size,  its  form,  its  con- 
sistence, the  size  of  the  os,  and  the  state  of  its  commissures.  Then 
the  finger  explores  the  posterior  cul-de-sac,  the  lateral,  the  anterior. 
This  examination  is  completed  only  by  combining  with  it  abdominal 
palpation,  that  is  to  say,  by  bimanual  exploration.  In  withdrawing, 
the  finger  sweeps  over  the  vaginal  walls  to  take  an  account  of  their 
condition.  It  may  be  that  the  uterus  is  very  high  and  the  cervix 
very  difficult  of  access,  deeper  exploration  can  then  be  accomplished 
by  introducing  the  middle  finger  with  the  index.  Thus  the  perinseum 
is  strongly  depressed.  Finally  in  some  cases  the  cervix  is  hidden 
behind  the  pubes  and  can  be  examined  only  with  the  woman  in  the 
genu-pectoral  or  in  Sims'  position.  Exceptionally  the  woman  may 
be  examined  in  the  upright  position  (displacemients,  abdominal 
tumors).  The  presence  of  the  hymen  may  be  an  obstacle  to  ex- 
amination. However,  this  membrane  is  usually  so  distensible  that 
cautious  digital  examination  can  be  made  without  tearing  it.  This 
procedure  being  somewhat  painful,  it  may  be  necessary  to  use  chloro- 
form, if  sufficient  ansesthesia  cannot  be  induced  by  cocaine.  Rectal 
touch  cannot  replace  the  vaginal  completely,  as  some  authors  assert. 
Rectal  touch. — It  is  especially  to  examine  the  state  of  Douglas'  cul- 
de-sac  and  of  the  posterior  surface  of  the  uterus  that  it  is  necessary 
to  introduce  the  finger  into  the  rectum.  Tumefactions  and  tumors 
of  this  region  cannot  be  thoroughly  examined  in  any  other  way.  It 
is  also  useful  to  verify  thus  the  absence  of  fecal  lumps,  which,  felt 
through  the  vagina,  may  be  taken  for  pathological  products.  On 
the  contrary  I  have  seen  beginners  feel  the  cervix  through  the  rectum 
and  mistake  it  for  a  tumor.  The  combination  of  vaginal  and  of 
rectal  examination  is  useful  to  ascertain  the  state  of  the  recto- 
vaginal septum.  Manual  examination  of  the  rectum  is  resorted  to 
in  exceptional  cases.  The  patient  being  anaesthetized,  the  sphincter 
is  dilated  as  for  anal  fissure  and  the  fingers,  massed  together  and 
smeared  with  vaseline,  are  gradually  introduced  into  the  orifice. 


62  Gyncecological  Examinations. 

I  eoiisider  this  procedure  dangerous,  especially  if  the  hand  of  the 
surgeon  is  not  paiiicularly  narrow  and  flexible. 

Vesical  touch  has  only  a  very  restideted  appHcation.  The  extreme 
dHatahility  of  the  female  urethra  usually  allows  introduction  of  the 
finger  without  cutting.  It  has  been  advised  in  cancer  of  the  uterus 
with  doubtful  invasion  of  the  vesical  wall.  The  association  of  vesical 
and  of  rectal  touch  is  of  great  service  in  atresia  vaginae,  to  examine 
the  uterus  and  the  tubes.  Finally  I  need  only  mention  the  com- 
bination of  rectal  or  vaginal  examination  mth  a  catheter  in  the 
bladder. 

Bimanual  exploration. — I  have  separately  described  vaginal  and 
rectal  examination  for  the  sake  of  convenience.  But  in  practice  they 
are  rarely  made  Avithout  the  aid  of  abdominal  palpation.  The 
patient  is  placed  in  the  dorsal  decubitus  or,  in  case  tliis  presents 
some  difficulty,  in  the  lithotomy  position.  Wliile  the  index  finger  of 
the  right  hand  practices  the  vaginal  examination  explained  above, 
the  left  hand  is  placed  over  the  pubes  and  the  fingers  pressed  gently 
in,  pusliing  the  internal  genitals  toward  the  vaginal  finger.  First  is 
attempted  an  accurate  account  of  the  position  of  the  uterus  in  the 
hypogastrium,  then  the  lateral  parts  are  examined,  and  while  the 
abdominal  hand  depresses  the  flanks  the  vaginal  finger  meets  it  by 
exploring  the  culs-de-sac.  Thus  are  explored  the  broad  ligaments 
and  the  uterine  appendages.  At  the  same  time  are  noted  the  sensi- 
tiveness of  the  parts ;  in  health,  pressure  on  the  appendages  and 
baUottement  of  the  uterus  are  not  painful.  Bimanual  examination 
may  also  be  made  Ijy  combining  abdominal  palpation  AAdth  the  rectal 
touch.     It  is  then  useful  for  exploration  of  the  api^endages. 

"With  bimanual  examination,  in  tliin  females,  the  ovaries  can  be 
palpated  without,  and  especially  with,  anaesthesia.  If  the  uterus  is 
drawn  down  by  an  assistant  holding  a  volseUa  fixed  in  the  cervix, 
wliile  duriirg  abdominal  palpation  one  finger  is  in  the  vagina  or 
rectum,  the  ovary  will  ghde  between  the  two  fingers  feeUng  like  a 
small  testicle.  The  left  is  generally  more  accessible  than  the  right, 
Avliich  is  attributed  to  the  fact  that  the  rectum  pushes  it  forward. 
However  that  may  be,  this  examination  presents  great  difficulties, 
especially  in  women  with  thick  abdominal  walls. 

In  difficult  cases,  where  exploration  of  the  ovaries  appears  in- 
dispensable, the  bladder  is  emptied  and  into  the  rectum  is  introduced 
a  rubber  bag  filled  with  two  hundred  or  two  hundred  and  fifty 
gi'ammes  of  water.  If  bimanual  exploration  is  made  now  it  ■niU  be 
found  that  the  uterme  appendages  are  pushed  up  and  supported  on 
a  resisting  plane  so  that  they  are  more  accessible. 

Examination  ■with  the  speculum. — Speculums  are  of  three 
types :  the  cylindrical,  the  univalve  and  speculums  mih  two  or  more 
valves. 

Cylindrical  speculums  are  especially  useful  for  topical  applications 


Gyncecological  Examinations. 


63 


(Fig.  28).  Of  wood  or  ivory,  they  protect  the  vaginal  walls  against 
the  action  of  the  heat  of  a  cautery;  of  glass,  they  are  valuable  for 
their  good  illumination,  for  the  facility  of  introduction  and  for  ap- 
plications to  the  cervix.  It  is  necessary  to  have  at  least  three  sizes 
of  this  speculum.  Before  introduction  the  speculum  should  be 
dipped  in  warm  water.  The  exterior  is  smeared  with  vaseline  and 
the  instrument  introduced  with  one  hand  while  the  other  separates 
the  ^^alvar  parts.  The  position  of  the  cervix  should  have  been  previ- 
ously ascertained  by  digital  examination,  to  know  what  direction  to 
give  the  instrument.  The  speculum  will  be  made  to  glide  over  the 
fourchette,  depressing  it  strongly,  avoiding  pressure  against  the 
anterior  wall  of  the  vagina  as  much  as  possible.  As  soon  as  the 
vulvar  ring  is  passed,  the  instrument  is  inclined  in  the  direction  of 
the  cervix.  The  beaJv  of  the  Fergusson  speculum  should  always  be 
directed  backward. 


Fig.  28. — Ferguson's  tubular  speculum. 

Speculums  of  several  valves. — The  bivalve  instruments  (Fig.  29)  are 
preferable.  Their  introduction  is  made  in  accordance  with  the  same 
principles  as  those  given  for  the  Fergusson.  The  valves  are  sepa- 
rated only  after  the  whole  extent  of  the  speculum  has  entered,  to 
avoid  distending  the  vulvar  orifice.  As  to  the  instruments  of  more 
than  two  valves  I  will  only  mention  Meadow's,  Bozeman's  and  Nott's 
(Figs.  30,  31,  32). 


Fig.  29. — Brewer's  bivalve  speculum. 

Univalve  speculums  are  especially  useful  for  purposes  of  operation. 
With  a  single  one,  access  to  the  wall  of  the  vagina  opposite  to  the 
speculum  is  possible  and  the  cervix  is  also  brought  into  view,  with 


64 


Gyncecological  Examinations. 


the  patient  in  Sims'  position.  With  two  valves,  simultaneously 
employed,  we  have  the  best  possible  means  for  examination  of  the 
vagina  and  cervix,  the  only  inconvenience  lies  in  the  necessity  for 
an  assistant. 


Open. 


Fig.  30. — Meadow's  quatrivalve  srtculum. 


G.  r/CMANfJ-CO. 

F;g.  31. — Bozeman's  speculum. 


Fig.  32. — Nott's  speculum  (plain). 


Gynacological  Examinations.  65 

Sims'  speculum  (Fig.  33)  or  depressor  is  intended  for  use  with  the 
patient  in  the  latere- abdominal  position.  In  this  lateral  position, 
this  instrument  offers  no  inconvenience,  but  in  the  dorsal  position 
the  shape  of  Sims'  speculum  makes  it  almost  impossible  to  use  the 
double  retractor.  For  this  position  a  single  retractor,  mounted  on 
a  handle,  is  preferable.  Besides  using  two  of  these  to  retract,  one 
the  anterior  .and  one  the  posterior  wall,  a  tlm-d,  and  even  a  fourth, 
can  be  inserted  to  hold  back  the  lateral  walls. 


Fig,  33. — Sims'  speculum. 

The  use  of  the  uterine  sound. — The  various  models  of  the 
uterine  sound  have  been  greatly  multipUed  without  any  real  gain  in 
value.  The  simplest  is  the  best.  It  may  be  reduced  to  a  simple" 
metaUic  probe,  terminating  above  in  a  small  l)ulb,  below  in  a  handle, 
which  serves  both  for  grasping  it  and  as  an  indicator  of  the  position 
of  the  uterine  extremity.  It  should  have  a  certain  rigidity,  but  yet 
retain  sufficient  flexibility  to  receive  and  preserve  the  different 
curvatures  that  it  may  be  desirable  to  give  it.  Inflexible  sounds 
should  be  rejected.  It  is  also  necessary  to  proscribe  the  slides  in- 
tended to  mark  the  depth  to  which  the  instrument  enters  the  uterus. 
As  a  substitute  for  these  the  sound  can  be  seized  in  the  jaws  of  a 
pair  of  forceps  at  the  os  uteri. 

The  uterus  should  never  be  sounded  without  having  previously 
acquired  some  idea  of  its  position  and  condition  by  bimanuel  ex- 
amination. The  most  favorable  position  for  using  the  sound  is  the 
dorso-sacral.  It  can  be  used  without  the  aid  of  a  speculum  by 
gliding  the  sound  over  the  palmer  surface  of  the  index  finger,  which 
guides  it  into  the  os  uteri.  The  finger-nail  can  be  used  to  mark  the 
depth  to  which  the  probe  has  entered.  But  it  is  far  preferable  to 
probe  the  uterus  with  the  aid  of  the  speculum,  and  it  may  be  made 
even  easier  by  fixing  the  cervix  at  the  same  time  with  a  forceps  or 
tenaculum.  In  some  cases  this  is  the  only  means  of  reaching  the 
OS  uteri,  when  the  cervix  is  luxated  into  one  or  other  cul-de-sac  by 
deviation  of  the  body.  It  may  be  added  that  a  slight  traction  on 
the  cer\d$:  considerably  facilitates  exploration- by  straightening  the 
cavity. 

The  most  rigorous  antisepsis  is  indispensable  in  probing  the 
uterus ;  not  only  should  the  instrument  be  disinfected  but  it  should 


66  GyruBcological  Examinations. 

be  passed  thi-ough  the  flame  of  an  alcohol  lamp  always  after  using. 
A  vaginal  injection  and  an  antiseptic  cleansing  of  the  cenical  canal, 
\\ith  a  bit  of  absorbent  cotton  twisted  on  a  probe,  are  necessary 
before  the  introduction  of  the  sound.  In  using  the  uterine  sound  be 
assm-ed  of  two  capital  points  :  1.  That  the  uteras  is  empty ;  2.  That 
the  sound  is  rigorously  aseptic. 

The  use  of  the  uterine  sound  gives  an  exact  knowledge  of  the  state 
of  the  cervical  canal,  of  the  longitudinal  diameter  of  the  uteras  and 
also  its  transverse  diameter,  and  of  the  direction  of  the  canal.  In 
the  normal  state  the  sound  penetrates  easily,  except  for  a  slight  re- 
sistance at  the  internal  os.  It  passes  to  a  depth  varying  fi-om  five 
or  six  centimetres  in  the  nulliparous  woman  to  six  or  seven  in  those 
who  have  borne  childi-en.  The  extent  of  the  lateral  movement  which 
can  be  given  to  the  sound  is  very  limited.  When  the  uterine  ex- 
tremity can  be  turned  in  various  directions  the  cavity  is  enlarged. 

Can  the  sound  be  passed  by  chance  into  the  tubes?  This  is  the 
explanation  given  by  a  number  of  authorities  in  cases  where  the 
instrament  has  been  pushed  far  into  the  abdomen  and  has  been  felt 
vmder  the  skin.  That  this  may  be  possible,  it  is  necessary  that 
some  very  exceptional  conditions  be  present,  as  latero-version  of  the 
uteiTis,  bringing  the  opening  of  the  tube  in  the  prolongation  of  the 
a3ds  of  the  cervix,  and  abnormal  enlargement  of  that  orifice.  This 
existed  in  an  observation  made  by  Bischoff .  In  almost  aU  the  cases 
published  as  supposed  catheterism  of  the  tubes,  it  is  probable  that 
there  was  a  uterine  perforation.  It  is  also  necessary  to  note  the 
possibihty  of  permanent  false  passages  (metro-peritonaeal  fistulae) 
permitting  the  introduction  of  the  sound  into  the  peritonaeal  cavity. 

Fixation  and  depression  of  tlie  uterus. — I  believe  that 
this  manoeuvre  should  be  classed  among  the  means  of  exploration, 
not  that  it  is  such  by  itself,  but  because  it  renders  great  service 
when  associated  -with  other  procedures.  Hegar  has  shown  that  it  is 
possible  to  explore  the  whole  of  the  posterior  surface  of  the  uterus 
even  to  the  fundus,  by  rectal  touch,  pro\-ided  the  cenix  is  seized 
^rith  the  forceps  and  the  uterus  di-awn  do^Mi  into  the  peh"ie  cavity. 
I  have  ah-eady  spoken  of  fixation  in  connection  -ndth  the  use  of  the 
uteiine  sound,  and  it  will  be  seen  that  direct  exploration  of  the 
\iteruie  cavity  will  caU  for  the  same  procedure.  Nothing  is  more 
harmless  than  a  moderate  downward  traction  of  the  utenis  when 
antiseptic  precautions  are  taken ;  even  forced  depression  (brmging 
the  cervix  to  the  vulva)  is  not  dangerous,  with  a  rigorous  anti- 
septicism.  I  have  daily  used  one  or  the  other  and  have  never  ob- 
served any  accident  that  could  be  attributed  to  this  procedui-e.  It  is 
necessary  to  remember  that  tliis  mauceuvre  is  mnocent  only  when 
there  exist  no  sjTnptoms  of  acute  or  subacute  perimetric  inflam- 
mation. I  beheve  it  is  useful  to  estabUsh  a  distiuctiou  between 
simple  fixation  and  depression.     The  first  consists  in  holding  the 


Gyncecological  Examinations.  67 

uterus  in  place,  drawn  downward  slightly,  without  stretching  the 
ligaments ;  the  second  carries  it  markedly  below  its  normal  level. 

The  technique  is  very  simple :  The  patient  being  in  the  dorso- 
sacral  position  the  anterior  hp  of  the  cervix  is  seized  through  the 
speculum  with  a  volseUa  or  tenaculum  forceps  (Fig.  34),  and  held 
firmly,  or  drawn  down  to  a  lower  level. 


Fig.  34. — Wooster's  tenaculum  forceps. 

Artificial  dilatation  and  intrauterine  touch.. — There  are 
some  rare  cases  where  exploration  of  the  uterine  cavity  with  the 
finger  is  necessary  to  confirm  the  diagnosis  (or  as  a  prehminary  to 
an  operation).  Different  means  have  been  proposed  to  attain  this 
end.  One  distinction  is  indispensable  :  the  cervical  canal  is  not  an 
orifice,  it  is  a  canal  that  has  a  superior  supravaginal  opening,  a  cavity 
of  narrow  dimensions  and  an  external  orifice.  Now  the  conditions 
vary  greatly,  according  to  the  state  of  these  different  portions,  not 
only  according  to  their  dilatation  but  to  their  dilatability  What  is 
necessary  to  consider  especially  is  the  state  of  the  internal  opening 
and  of  the  supravaginal  part  of  the  cervical  canal.  There  are  cases 
where  their  dila-tation,  or  at  least  their  softening,  leaves  no  obstacle 
in  the  way  of  reaching  the  mucosa  of  the  body  of  the  uterus,  for  ex- 
ample, in  fibrous  tumors  or  intrauterine  polypi,  after  abortion,  etc. 
These  cases  are  essentially  different  from  those  where  the  whole 
length  of  the  cervix  is  rigid.  Procedures  which  apply  in  the  one  case 
do  not  find  place  in  the  other. 

In  passing  these  procedures  in  review  I  will  indicate  the  best.  We 
can  divide  them  into  two  classes :  1.  Non-bloody,  which  include : 
(a)  slow  dilatation  with  turgescent  substances;  (b)  divulsion;  (0) 
immediate  progressive  dilatation.  2.  Bloody  procedures,  compris- 
ing two  operations :  (a)  incision  of  the  external  orifice ;  (b)  total 
bilateral  incision  of  the  cervix.  None  of  these  operations  should  be 
used  unless  absolutely  necessary  and  all  intrauterine  explorations 
should  be  regarded  as  dangerous. 

Non-bloody  procedures. — (a).  Slojc  dilatation  with,  tuvgescent 
substances  is  made  by  introducing  into  the  cervix  tents  of  various 
kinds.  In  turn,  there  have  been  advised,  prepared  sponge,  lami- 
naria,  gentian  root,  decalcified  ivory,  tupelo,  etc.  Laminaria,  to  me, 
appears  the  best,  and  though  I  do  not  absolutely  reject  prepared 


68  GyiKScolof/ical  Examviatious. 

sponge,  rendered  antiseptic,  I  believe  its  appKcations  are  very  limited. 
Laminaria  is  sufficient  for  almost  every  need.  It  is  employed  as 
follows,  after  being  disinfected  by  immersion  in  a  solution  of  iodoform 
in  ether :  The  vagina  is  cleansed  with  care.  The  patient  is  placed 
in  the  dorso-sacral  position  and  the  cervix  exposed  \vith  a  bivalve 
speculum.  It  is  of  advantage  then  to  seize  the  anterior  hps  with 
the  volseUa  and  thus  fix  the  cervix  during  the  introduction  of  the 
tent.  Care  is  pre^iously  taken  to  ascertain  the  position  of  the  uterus 
by  bimanual  examination  and  the  uterme  sound.  The  tent  can  then 
be  bent  sHghtly  to  adapt  it  to  the  cun'e  of  the  uterine  canal.  The 
tent,  coated  weU  mth  vasehne,  is  fixed  in  the  jaws  of  the  forceps  and 
gently  introduced.  It  is  not  necessary  that  its  extremity  (to  which  a 
thread  is  fastened)  should  disappear  mthin  the  cer\ical  cavity.  If 
the  introduction  of  a  single  tent  of  sufficient  size  is  too  difficult,  two 
or  three  smaller  tents  may  take  its  place ;  ■violence  should  never 
be  used  in  pushing  them  into  the  cavity.  The  volseUa  removed, 
a  tampon  of  iodoform  gauze  is  placed  against  the  cervix  and  the 
speculum  withdrawn.  About  ten  hours  are  necessary  for  complete 
sweUing  of  the  laminaria.  The  tents  are  usually  removed  by  aid  of 
the  thread  which  is  attached  to  the  vaginal  extremity.  It  sometimes 
happens  that  this  is  difficult,  the  dilatation  having  taken  an  hour- 
glass form  (Fig.  35).  It  is  then  necessary  to  seize  the  end  ^vith  the 
forceps  and  withdraw  by  traction  combined  with  rotation,  while  the 
finger  furnishes  a  support  to  the  cervix  during  the  dislodgement  of 
the  tent.  In  spite  of  aU  antiseptic  precaution  this  slow  dilatation 
cannot  be  considered  inoffensive.  Symptoms  of  acute  metritis  are 
sometimes  observed  with  intense  paui  and  a  marked  febrile  dis- 
turbance. 

(b).  Divulsion  or  immediate  forced  dilatation  has  given  rise  to 
many  instruments.  I  prefer  EUinger's  dilator,  with  two  parallel 
blades.  Most  of  the  dther  instniments  have  the  disadvantage  of 
taking  their  supporting  points  on  too  Umited  an  area. 

(c).  Immediate  progressive  dilatation. — This  mode  of  dilatation  is 
well  kno^vn  to  general  sm'geons,  as  they  have  long  applied  it  to  the 
treatment  of  stricture  of  the  urethra.  Hegar's  dilators  seem  to  be 
the  most  convenient.  They  are  bougies  of  hard  ruliber,  cylindrical, 
and  conical  at  theii-  extremity.  Then  length  is  from  twelve  to  four- 
teen centimetres,  not  incluchng  the  handle  which  is  five  centimetres 
long.  The  diameter  of  No.  1  is  two  miUimetres,  and  it  increases 
by  one  mOlimetre  for  each  bougie ;  this  increase  is  a  Httle  too  rapid 
for  the  high  numbers  and  it  is  better,  in  difficult  cases,  to  have  the 
diameter  increase  by  one-half  millimetre  only.  They  should  be 
kept  in  a  strong  carbolic  solution.  The  patient  is  aniesthetized  and 
put  in  the  dorso-sacral  position  (Hegar  prefers  Sims'  position). 
The  fourchette  is  pressed  back  with  a  short  retractor,  the  anterior 
hp  of  the  cervix  is  seized  and  fixed  with  the  vnlsellum  and  the  exact 


Gynmcological  Examinations . 


69 


direction  of  the  uterus  is  ascertained  by  bimanual  examination  and 
the  sound.  The  first  dilator  is  then  dipped  in  vaseline  and  intro- 
duced. It  should  be  of  a  diameter  that  will  pass  into  the  cavity 
with  gentle  pressure.  Immediately  after,  a  second  and  then  a  third 
is  passed.  If  resistance  is  met  with,  the  dilator  is  allowed  to  remain 
from  one  to  three  minutes.  It  is  possible  to  reach  very  quickly,  in 
a  quarter  of  an  hour,  a  dilatation  of  the  cervix,  naturally  or  arti- 
ficially softened,  sufficient  to  aUow  the  introduction  of  the  entire 
index  finger.  When  the  cervix  is  not  softened,  an  hour,  and  even 
more,  may  be  necessary  to  attain  tliis  result.  Thus  it  finds  its 
greatest  usefulness  after  miscarriages  and  in  certain  morbid  states. 
If  it  is  necessary  to  use  this  method  in  the  case  of  a  rigid  cervix,  a 
laminaria  tent  may  be  first  introduced  to  induce  a  commencement 
of  the  dilatation  and  dilatability  of  the  tissues.  When  this  tent  is 
■withdrawn  the  dilatation  is  rapidly  completed  by  Hegar's  dilators. 


Fig.  35. — Laminaria  tents  before  and  after  their  use. 

Bloody  procedures  for  dilatation  of  the  cervix  are  indicated,  either 
when  the  only  obstacle  to  the  introduction  of  the  finger  is  located  at 
the  external  orifice  alone,  when  the  urgency  of  the  case  will  not  per- 
mit the  loss  of  an  instant,  or,  finally,  when  the  surgeon  has  not  at 
hand  the  special  instruments  for  bloodless  dilatation. 

(a).  Incision  of  the  external  as. — It  is  sometimes  sufficient  to 
make  an  incision  on  each  side  of  the  orifice  to  permit  entrance  into 


70  Gynfecolofi'icnl  E.rani'inations. 

an  already  enlarged  cervical  cavity.  Then  this  method  is  the  most 
simple  and  expeditious.  Scissors  with  long  handles  may  be  used, 
after  insertion  of  the  speculum  and  fixation  of  the  cervix.  Kuchen- 
meister  has  constructed  special  scissors  for  tliis  purpose,  but  they 
are  not  indispensable.  An  incision  of  fi-om  one  centimetre  to  one 
and  one-half  on  each  side  will  be  sufficient  for  the  passage  of  the 
index  finger.  After  the  exploration  and  intrauterine  irrigation  the 
incisions  should  be  closed  with  catgut. 

(b).  Complete  bilateral  incision. — It  is  necessary  to  make  a  pre- 
liminary ligation  of  the  uterine  arteries.  The  patient  bemg  anaes- 
thetized and  in  the  dorso-sacral  position,  the  fourchette  is  depressed 
with  a  short  Sims'  speculum  and  the  vagina  drawn  to  one  side 
with  a  retractor,  while  a  tenaculum  forceps  draws  the  eei-vix  to 
the  opposite  side;  one  of  the  lateral  culs-de-sac  is  thus  accessible. 
Tliis  is  explored  mth  the  finger  for  the  throbbing  of  the  uterine 
artery.  A  strongly-curved  needle,  threaded  "nith  silk,  is  then 
entered  in  the  cul-de-sac  a  finger's  breadth  beyond  the  cervix,  taking 
care  not  to  pass  the  transverse  line  representing  a  tangent  to  the 
cervix  anteriorly,  to  avoid  the  ureter.  With  this  needle  the  greatest 
possible  thickness  is  seized  and  it  is  brought  out  posteriorly  in  the 
vagina  as  nearly  as  possible  to  its  point  of  entry  and  always  at  the 
same  distance  from  the  cervix.  By  approximating  the  point  of 
entry  to  that  of  exit  less  of  the  vaginal  mucous  membrane  is  in- 
cluded in  the  loop.  This  loop  of  silk  is  tied  tightly,  and  we  proceed 
in  hke  manner  mth  the  opposite  side.  This  done  the'  Instom-y  can 
be  used  N^dthout  fear  of  hfemorrhage.  The  cervix  being  drawn 
doAvn,  an  incision  is  made  on  each  side  as  far  as  the  vaginal  insertion, 
and  attempt  is  made  to  pass  the  finger  to  the  uterine  cavity.  If  this 
proves  difficult,  a  probe-pointed  bistoury  is  introduced  into  the 
cervix  along  the  palmer  surface  of  the  finger  and  in  returning  scari- 
fies each  side  of  the  internal  surface  of  the  cervix  until  the  finger 
can  enter. 

After  exploration  and  irrigation  the  cervix  must  be  restored  with 
great  care.  For  this  purpose  a  needle  threaded  mth  catgut  is 
pushed  deeply  into  the  cerxdx,  at  its  junction  with  the  vagina,  and, 
guiding  it  by  the  finger,  an  attempt  is  made  to  pass  the  suture 
across  the  cervical  canty  at  the  highest  point  of  the  incision.  It  is 
necessary  to  place  the  symmetrical  suture  of  the  other  side  before 
tying  the  first ;  without  tliis,  the  ca^dty  being  narrowed,  the  finger 
cannot  perform  its  office  as  a  guide.  The  two  superior  stitches 
being  placed  and  tied,  a  sufiicient  number  of  sutures  are  placed 
below  them,  care  being  taken  to  produce  as  perfect  coaptation  of  the 
mucosa  of  the  cervical  canal  as  of  that  outside.  It  is  useless  to 
leave  the  ligature  of  the  uterine  arteries  in  place  indefinitely.  Save 
on  special  indications  it  can  be  cut  at  the  end  of  three  or  four  hours. 
It  is  not  necessary  to  dwell  on  the  fact  that  this  ablation  will  be 


Gyncecological  Examinations.  71 

urgent  if  the  symptoms  cause  fear  of  having  inchided  the  ureters 
in  the  ligatures. 

Permanent  dilatation. — Dilatation  once  accomplished,  by  whatso- 
ever means,  it  is  possible  to  maintain  it  by  tamponing  the  uterine 
and  cervical  cavities.  Recently  attempts  have  been  made  to  apply 
this  method  in  the  diagnosis  and  the  treatment  of  certain  uterine 
affections,  as  it  makes  it  possible  to  observe  their  evolution.  Vulliet, 
who  advocates  this  continued  dilatation,  proceeds  as  follows  :  The 
patieiit  being  in  the  genu-pectoral  position  and  the  cervix  exposed 
with  a  speculum,  the  cervical  canal  is  explored.  If  it  is  strictured 
or  deviated,  a  preliminary  treatment  re-establishes  its  proper 
direction  or  caliber.  If  it  is  normal,  a  smaU  tampon  of  cotton  is 
placed  at  the  os  and  pressed  into  its  cavity.  These  tampons  vary 
in  size  from  that  of  a  pea  to  that  of  an  almond,  and  each  has  a 
thread  attached.  They  are  first  immersed  in  a  solution  composed 
of  one  part  of  iodoform  to  ten  parts  of  ether,  then  dried  and  pre- 
served in  a  tightly- corked  bottle.  VuUiet  introduces  the  tampons 
successively  until  the  cavity  is  fiUed  to  the  external  orifice.  They 
are  withdrawn  at  the  end  of  forty-eight  hours.  If  they  have  been 
well  packed,  the  walls  have  softened  and  given  way  by  this  time  and 
there  is  formed  a  free  space  of  which  the  operator  takes  possession 
by  introducing  a  greater  number  of  tampons  than  the  first  time. 
Proceeding  thus  with  tampons  gradually  increasing  in  size,  eight  or 
ten  insertions  will  be  sufficient  to  accomplish  such  a  degree  of  dila- 
tation that  the  cavity  of  the  uterus  will  be  visible  throughout  its 
whole  extent.  To  gain  time  and  a  more  regular  dilation,  it  is  an 
advantage,  according  to  Vulliet,  to  substitute  for  the  tampons  an 
occasional  laminaria  tent.  This  procedure  is  not  always  appli- 
cable even  in  the  conditions  indicated  by  its  originator.  There 
are  a  certain  number  of  cases  where  complete  dilatation  cannot 
be  obtained  and  others  where  it  is  necessary  to  stop  the  repeated 
introduction  of  the  tampons,  either  because  they  produce  too  much 
pain,  or  because  they  provoke  nervous  symptoms.  However,  I  do 
not  believe  that  inspection  of  the  uterine  cavity  can  furnish  any 
information  not  obtainable  by  the  methods  previously  described, 
and  it  is  probable  that  Vulliet's  method  of  exploration  will  not  long 
survive  the  interest  awakened  by  its  novelty.  This  remark  does 
not  apply,  however,  to  haemostatic  or  antiseptic  tamponnement  of 
the  uterus. 

Examination  with  the  index  finger  in  the  uterine  cavity  permits 
full  knowledge  of  softening  or  irregularities  of  the  walls,  vegetations, 
tumors,  or  abnormal  growths  in  the  cavity.  This  exploration  is 
always  combined  with  hypogastric  palpation.  It  should  be  quickly 
performed  and  should  be  followed  by  an  intrauterine  injection  of 
carbolized  water,  1-100,  by  the  application  of  an  iodoform  tampon, 
and  by  rest  in  bed  for  two  days.     If  the  htemorrhage,  which  is 


72  Gyncecoloyical  Examinations. 

exceptionally  provoked,  does  not  yield  to  very  hot  intrauterine 
injections  (45^  C.  to  50-  C),  tlie  uterine  cavity  is  tamponed  for  a  few 
hours  with  iodoform  gauze. 

,  Excision  or  curetting  for  the  purpose  of  securing  microscopical 
specimens  for  differential  diagnosis,  is  sometimes  necessary,  es- 
pecially in  doubtful  cases  of  carcinoma.  The  technique  of  excision 
is  most  simple :  it  consists  of  fixation  of  the  cervix,  excision  of  a 
fragment  Avith  the  narrow  scissors  or  with  the  bistoury,  and  sub- 
sequent hsemostasis  if  necessary  by  the  thermo-cautery.  When  it 
is  necessary  to  determine  the  condition  of  the  uterine  mucosa, 
scraping  with  the  curette  will  furnish  sections  sufficient  for  ex- 
amination. The  use  of  the  curette  will  be  described  in  detail  in 
connection  with  the  subject  of  metritis. 

Exploration  of  the  ureters.  —  (a).  Palpation.  —  The  ana- 
tomical relations  of  these  organs  to  the  cervix  uteri  and  to  the 
vagina  have  been  specially  studied  in  recent  years  on  account  of 
the  extreme  importance  of  this  knowledge  in  certain  operations. 
It  is  known  that  it  is  possible  to  feel  thi'ough  the  vagina  the  anterior 
portion  of  the  pelvic  division  of  the  ureters,  when  injected  in  the 
cadaver,  passing  from  the  bladder  to  the  base  of  the  broad  liga- 
ments, equal  to  about  six  to  seven  centimetres  in  extent,  that  is, 
half  their  pelvic  or  a  quarter  of  their  total  length.  In  pregnant 
women  it  is  possible  to  recognize  them  to  a  length  of  ten  centi- 
metres. Sanger  has  been  able  to  identify  the  ureters  when  notably 
indurated  in  cases  of  blennorrhagic  ureteritis  and  calculous  pyelo- 
ureteritis.  When  there  is  an  old  inflammation  of  the  broad  liga- 
ment the  ureter  is  found  enlarged  on  the  opposite  side,  as  if  it  had 
undergone  hypertrophy.  I  believe,  however,  on  account  of  the 
great  difficulties  which  it  presents,  as  well  as  the  uncertainty  of  its 
results  and  the  rarity  of  practical  deductions,  that  this  method  of 
examination  will  never  come  into  general  use.  But,  as  there  are 
a  few  to  whom  it  may  be  of  service,  I  give  its  technique.  Some 
anatomical  considerations  present  themselves.  The  field  of  these 
researches  is  limited  to  the  superior  third  of  the  anterior  wall  of 
the  vagina.  Schematically,  this  is  a  trapezium,  of  which  the 
oblique  and  diverging  sides  correspond  to  the  ureters  and  to  the 
union  of  the  anterior  wall  with  the  lateral  walls  of  the  vagina.  The 
small  base  of  this  trapezium,  or  better,  the  blunted  extremity  of  a 
triangle,  is  horizontal  and  inferior ;  it  correspends  to  the  inter- 
ureteral  ligament.  The  long  side  of  the  trapezium,  horizontal  and 
superior,  is  formed  by  a  line  uniting  the  points  where  the  ureters 
emerge  from  the  broad  ligaments.  In  this  space,  in  certain  cir- 
cumstances, the  finger  recognizes,  at  one  and  a  half  to  two  centi- 
metres be5'ond  the  os  uteri  in  the  thickness  of  the  vaginal  septum, 
two  cords,  hard,  longitudinal,  directed  backward,  from  -within 
outward,  and  from  below  upward,  describing  a  concavity  opening 


Gynaecological  Examinations. 


73 


inward  (Fig.  36).  Ordinarily  they  cannot  be  made  out  to  their 
whole  accessible  length,  which  is  six  to  seven  centimetres  from  the 
base  of  the  vesical  triangle,  indeed  in  some  cases  only  for  a  distance 
of  two  centimetres. 


'  w 

^'7 

:      ..•"'/ 

':  --'__ 

Fig.  36. — Portion  of  the  ureters  accessible  to  touch.  (Schematic:  the  posterior 
vaginal  wall  removed  and  the  ureters  supposed  to  be  seen  through  transparent  tissues.) 
a,  base  of  broad  ligament;  b,  ureter;  c,  cervix  uteri;  d,  inter-ureteral  ligament;  e, 
vesical  trigone;  f,  urethra;  g,  vagina. 

Normally  the  ureters  are  symmetrical,  but  they  cease  to  be  so  in 
consequence  of  various  lesions,  and  then  their  direction  becomes 
devious  (cicatricial  retractions),  so  that  the  ureter  of  one  side  is 
found  carried  toward  the  opposite  side,  or  that  the  concavity  is 
directed  upward  instead  of  inward.  Finally,  only  a  single  ureter 
can  be  felt  in  some  cases.  The  normal  ureters  have  a  diameter  of 
about  one  millimetre ;  in  disease  they  acquire  the  diameter  of  a 
goosequill  or  even  that  of  a  large  pencil.  They  are  more  or  less 
mobile  under  the  fingers,  or  fixed  in  the  tissues  by  the  exudation  of 
periureteritis.  In  the  normal  state  they  are  not  sensitive ;  ab- 
normally they  become  more  or  less  sensitive  to  pressure. 

By  vaginal  examination  we  seek  them  thus :  With  the  index 
finger  the  urethra  is  followed  to  its  junction  with  the  bladder,  thus 
the  anterior  vaginal  cul-de-sac  is  reached,  care  being  taken  to 
recognize  the  direction  of  the  cervix  uteri.  It  is  in  the  portion  of 
the  anterior  vaginal  wall  comprised  between  the  internal  orifice  of 
the  urethra  and  the  anterior  cul-de-sac  of  the  vagina  that  we  seek 


74  Gynecological  Examinations. 

the  ureters.  This  region  extends  scarcely  more  than  two  to  five 
centimetres  and  is  distinguished  by  great  laxity.  "With  the  lateral 
surface  of  the  finger  the  anterior  and  lateral  vaginal  walls  are  pal- 
pated in  the  direction  of  the  broad  ligament.  For  the  right  ureter 
the  right  index  finger  is  used,  and  for  the  left  ureter,  the  left  index. 
Nevertheless  the  right  finger  can  be  used  in  palpation  of  the  left 
ureter,  but  it  is  then  the  palmar  surface  that  seeks  it.  At  first  it 
is  necessary  to  proceed  carefully,  slipping  the  finger  little  by  little 
along  the  anterior  vaginal  wall.  To  delicate  palpation,  the  ureter, 
when  normal  or  only  slighly  hypertrophied,  feels  like  an  artery 
deprived  of  pulsation.  When  the  ureters  can  be  compressed 
against  a  hard  body,  as  a  foetal  head,  they  are  displaced  in  their 
sheath  and  roll  under  the  finger.  Palpation  is  easier  when  the 
vesico-vaginal  wall  is  flaccid.  The  ureters  may  be  confounded 
with  the  arteries,  with  periuterine  cicatricial  cords,  and  according 
to  Sanger,  even  with  the  muscular  fasciculi  of  the  levator  ani  and 
of  the  sphincter  ani.  These  errors  are  avoided  by  taking  strict 
account  of  the  anatomical  or  the  anatomico-pathological  situation 
of  the  ui-eters. 

Catheterism.  of  the  ureters. — There  are  cases  where  it  would 
be  useful  to  determine  if  both  kidneys  are  diseased  or  if  one  only 
is  attacked.  Pawlik  has  been  able  to  demonstrate  the  utility  of 
this  procedure  in  one  case,  and  in  another  he  evacuated  a  hydro- 
nephi-osis,  and  even  allowed  the  catheter  to  remain  in  the  ureter. 
Some  anatomical  considerations  are  necessary  to  the  description 
of  the  technique  indicated  by  Pawlik  for  catheterism  of  the  ureter. 
The  openings  of  the  ureters  occupy,  in  front  of  the  has  fond  of  the 
bladder,  on  the  posterior  half  of  the  antero-inferior  wall,  the  two 
posterior  angles  of  Lieutaud's  trigone.  The  anterior  angle  of  this 
triangle  marks  the  situation  of  the  urethral  orifice.  Each  of  these 
thi'ee  openings  is  seated  in  the  center  of  a  more  or  less  cylindrical 
projection  consisting  of  a  muscular  thickening  and  covered  by 
mucous  membrane.  These  mamillated  projections  of  the  orifices 
of  the  ureters  serve  as  landmarks.  They  are  united  by  a  promi- 
nent transverse  band  of  the  same  structure,  thick  and  resisting 
enough,  even  in  its  middle  portion  where  it  is  thinned,  to  arrest 
the  end  of  a  sound  if  gently  pushed,  and  to  be  perceptible  to  direct 
palpation.  This  projection  is  called  the  inter-ureteral  ligament. 
It  constitutes  the  curvilinear  base  of  Lieutaud's  triangle,  the 
sides  of  which  are  indicated  by  similar  projections,  but  less 
marked,  converging  toward  the  urethra.  The  height  of  the  tri- 
angle, the  distance  from  the  urethra  to  the  middle  of  the  inter- 
iireteral  ligament  is  from  one  to  two  centimetres  (Warnoots),  or 
thi-ee  centimetres  (Hart). 

Pawlik  places  his  patients  in  the  genu-pectoral  position,  but 
the  catheterism  can  also  be  performed  in  the  dorso-sacral  position. 


Gynmcological  Examinations. 


75 


It  is  important  only  tlaat  the  head  be  placed  low  and  the  nates 
much  elevated  to  allow  the  viscera  to  fall  toward  the  diaphragm. 
A  large  retractor  is  introduced  and  the  posterior  vaginal  wall 
depressed,  thus  stretching  the  anterior  wall.  This  tension  of  the 
anterior  wall  permits  Pawlik  to  note  a  number  of  folds  of  great  im- 
importance,  as  regards  anatomical  topography.  He  notes  first, 
near  the  external  orifice  of  the  urethra,  an  elongated  ridge,  from 
before  backward,  median,  transversely  plaited,  well  marked,  cor- 
responding to  the  intraparietal  track  of  the  urethra.  This  ridge 
terminates  at  the  edge  of  the  vesical  orifice  of  the  uretln-a.  To  this 
ridge  succeeds  a  small  triangular  space,  corresponding  to  Lien- 
taud's  triangle,  bounded  by  three  projecting  folds  (Fig.  37).  On 
the  cadaver  it  has  been  determined  that  the  triangle  thus  limited 
on  the  vaginal  wall  corresponds,  line  for  line,  to  the  intravesical 
triangle  of  Lientaud.  It  has  been  called  the  vaginal  trigone  of 
Pawlik. 


-B 


Fig.  37. — Vaginal  trigone  of  Pawlik  on  the  anterior  vaginal  wall.  Z  L,  labia 
minora;  0,  urethral  orifice;  0'  O' ,  prominence  of  the  urethra;  Fi  mucosa  of  the 
cervix  ;  B,  transverse  fold  of  the  vagina  a  little  behind  the  inter-ureteral  ligament 
forming  the  base  of  the  trigone ;  S  S,  lateral  diverging  folds  of  the  vagina  correspond- 
ing to  sides  of  the  vesical  trigone. 

Pawlik  uses  a  metal  catheter  terminating  in  a  bulb.     Its  total 
length  is  twenty-five  centimetres,  the  beak  is  one  and  one-half 


76  ■  Gynecological  Examinations. 

millimetres  in  diameter.  The  eye  of  the  catheter  is  much 
elongated  and  has  rounded  edges.  It  is  situated  at  the  base  of 
the  beak  at  a  slight  curvature,  by  which  this  is  continuous  with 
the  rest  of  the  instrument,  which  is  somewhat  conical. 
ll  At  one  and  one-half  centimetres  from  the  other  extremity 
is  placed  an  octahedral  handle  (Fig.  38)  with  a  mark  on 
one  face  corresponding  to  the  direction  of  the  beak.  To 
render  the  instrument  aseptic,  the  wu-e  is  withdrawn  and 
water  injected,  then  it  is  filled  with  ether  several  times 
and  passed  thi-ough  the  flame  of  an  alcohol  lamp. 

Before  introducing  the  sound,  a  certain  degree  of  arti- 
ficial distention  of  the  bladder  must  be  induced.  The 
quickest  and  sui-est  way  is  to  completely  evacuate  the  organ 
and  then  inject  two  hundred  cubic  centimetres  of  water. 
The  ureteral  sound  is  then  withdrawn  and  the  ureteral 
catheter  introduced.  As  soon  as  this  has  passed  the  in- 
ternal urethi'al  opening,  the  handle  is  turned  so  as  to  bring 
the  beak  of  the  catheter  in  contact  with  the  vesico-vaginal 
septum.  The  bulb  of  the  instrument,  as  it  is  pushed  hghtly 
onward,  produces  a  projection  on  the  anterior  vaginal  wall. 
In  proportion  as  the  catheter  is  advanced  this  projection  is' 
displaced  and  the  instrument  can  be  thus  directed  along 
one  of  the  lateral  sides  of  the  vaginal  trigone  toward  the 
opening  of  the  ureter.  In  this  direction  is  met  the  most 
prominent  part  of  the  inter-ureteral  line.  If  the  sound  is 
kept  too  near  the  median  line  this  limit  may  be  passed 
without  perceiving  it,  as  its  middle  portion  is  much  flattened. 
Arriving  at  this  point,  the  sound  is  given  slight  movements 
of  gliding,  of  rotation,  of  elevation  and  of  depression,  but 
always  holding  it  to  the  region  of  one  of  the  angles  of  the 
vaginal  trigone,  which  is  constantly  kept  in  mind.  Once 
the  sound  is  engaged,  it  is  pushed  from  one  to  two  centi- 
metres toward  the  posterior  vesical  wall.  The  penetration 
of  the  catheter  into  the  ureter  is  recognized  by  the  fact  that 
no  resistance  is  felt  in  front  of  the  instriiment ;  on  the 
contrary,  lateral  movements  and  lowering  the  handle  are 
obstructed  in  proportion  to  the  distance  it  has  entered  the 
ureter.  At  the  end  of  some  time  the  urine  flows  from  the 
ureter  by  drops.  The  catheter  is  now  pushed  to  the  level 
of  the  superior  strait,  at  which  point  the  ureter  slightly 
changes  its  direction.  The  manoeu\Te  at  this  stage  becomes 
Fig.  38.  very  difficult,  especially  when  the  canal  of  the  urethi-a 
Ureteral  closely  hugs  the  pubes  and  is  but  slightly  distensible,  as  ui 
"f,g'"  nuUiparous  women ;  on  the  contrary,  if  the  urethi-a  is  large 
Pawlik.  and  flaccid,  there  is  not  much  difliculty  in  the  penetration. 
The  catheter  is  pushed  gently  onward  while  the  handle  is  lowered 


Metritis. — Pathological  Anatomy. — JEtiology.  77 

as  much  as  possible.  This  last  part  of  the  catheterism  is  as  easy  as 
the  first,  if  the  instrument  has  been  entered  through  a  fistula  in 
the  bladder  or  urethra. 

Thus  the  pelvis  of  the  kidney  is  reached.  The  ureter  has  become 
rectilinear.  Ordinarily  in  contact  with  the  pelvic  wall,  it  is  now 
separated  from  it  to  the  extent  of  four  and  one -half  centimeters. 
The  cellular  tissue  which  surrounds  the  ureter  permits  this  sepa- 
ration when  it  is  in  normal  condition  and  lax.  The  catheterism 
should  be  made  slowly  anfl  gently,  especially  if  there  is  reason 
to  fear  causing  an  inflammation  of  the  ureters.  The  only  serious 
consequences  that  have  been  noted  are,  fever,  abdominal  pains 
(not  lasting  more  than  twenty-four  hours),  a  mild,  circumscribed 
peritonitis  (in  a  case  where  it  had  previously  existed),  and  finally, 
in  the  urine  have  been  found  blood  and  epithelial  debris,  the 
products  of  traumatism  of  the  ureter.  It  is  not  impossible,  how- 
ever, that  this  catheterism  may  be  followed  by  ureteral  fever 
analogous  to  urethral  fever. 

If  catheterism  of  the  ureter  is  necessary,  and  the  method  advised 
by  Pawhk  appears  of  doubtful  propriety,  Simons'  method  may  be 
substituted:  chloroformization,  dilatation  of  the  urethja,  intro- 
duction of  the  catheter  on  the  finger,  which  directly  recognizes  the 
inter-ureteral  ligament  and  the  orifice  of  the  ureter.  Incontinence 
of  urine  need  not  cause  imeasiness ;  it  is  only  of  short  duration. 


CHAPTER  V. 


METRITIS.  — PATHOLOGICAL  ANATOMY.— 
-ffiTIOLOGY. 

Metritis.  —  Definition.  —  According  to  the  etymology  of  the 
word,  metritis  is  an  inflammation  of  the  uterus.  I  will  keep  to 
this  general  term  although  it  is  open  to  criticism.  The  generic 
term,  inflammation,  applies  to  all  these  morbid  states  of  which  the 
anatomical  substratum  is  confined  to  irritative  lesions  without 
termination  in  the  formation  of  specific  neoplasms.  How  numerous 
and  varied  these  lesions  are  will  soon  be  shown.  But  they  are  all 
united  in  one  class  by  their  characteristics  :  at  first  infectious,  then 
purely  defensive  and  limitative  in  their  evolution.  Whether  there 
is  proliferation  of  the  mucous  membrane  or  of  the  parenchyma, 
all  the  processes  consist  in  a  local  irritation,  proceeding  from  an 
external  or  internal  factor,  and  have  no  tendency  to  pass  certain 
limits.    Thus  the  metrites  are  clearly  distinguished  from  neoplasms, 


78  Metritis. — Pathological,  Anatomy. — ^-Etiology. 

properly  so-called.  Do  there  exist,  aside  from  metritis,  "  morbid 
states  without  neoplasms  "  which  merit  a  distinctive  nomenclature  ? 
Taking  as  a  basis  dogmatic  ideas  and  a  narrow  conception  of  in- 
flammation, the  older  aiithors  did  not  hesitate  to  exclude  from  the 
framework  of  metritis  all  which  was  not  comprehended  in  the  classic 
quartette,  swelling,  redness,  heat,  and  pain.  In  consequence  of  this, 
granulations,  ulcerations  and  leucorrhcea  each  became  a  separate 
disease.  We  find  traces  of  this  even  Avith  recent  writers.  Have 
they  not  described  fluxion  as  congestion,  engorgement,  cedema, 
hypertrophy,  arrest  of  involution,  granulations  and  ulcerations  of. 
the  cervix  ? 

The  idea  of  symptom  should  not  be  confounded  with  that  of  a 
disease.  Thus  it  is  that  other  authors  have  indicated  idiopathic 
metritis  and  symptomatic  metritis,  a  classification  that  we  will 
not  adopt.  Metritis  should  remain  a  clinical  term  and  not  an 
anatomo-pathological  one.  The  study  of  disease  serves  us  as  a 
guide,  that  of  the  anatomical  section  is  only  complementary. 
Because  there  are  lesions  of  endometritis  in  fibroids,  or  of  paren- 
chymatous metritis  in  cancer,  ought  we  to  describe  in  this  chapter 
myomatous  metritis  or  cancerous  metritis '?  That  would  be  per- 
plexing and  confusing  indeed.  Certainlj^  all  classifications  are 
somewhat  artificial  because  it  is  impossible  to  make  them  definite 
so  long  as  nothing  is  absolute  in  nature.  They  are  none  the  less 
indispensable,  and  justifiable  if  care  is  taken  to  specify  the  basis  on 
which  they  are  founded.  That  used  here  ^vill  be  the  cHnical,  which 
alone  gives  the  personality  of  the  disease.  I  cannot,  however, 
leave  this  subject  without  a  few  words  on  the  pseudo  metrites  or 
the  so-called  symptomatic  metrites. 

Inflammatory  lesions  of  the  uterine  mucosa  are  exceedingly  fre- 
quent in  fibroid  tumors,  and  it  is,  no  doubt,  to  these  changes  in  that 
membrane  that  the  haemorrhages  are  due.  The  irritation  is  pro- 
pagated in  these  cases  by  continuity  of  tissue.  It  is  in  the  same 
waj',  but  in  an  opposite  direction,  perhaps  even  in  consequence  of 
reflex  congestions  predisposing  to  infection,  that  the  lesions  of 
endometritis  occur  in  diseases  of  the  appendages.  These  pseudo 
metrites,  as  I  shall  call  them,  are  characterized  by  the  fact  that  the 
inflammation  of  the  uterine  mucous  membrane  is  here  only  an 
epiphenomenon  Mhich  follows  late  after  the  appearance  of  the 
symptoms  on  the  part  of  the  appendages  or  the  pelvic  peritonaeum. 

Divisions. — We  now  approach  the  study  of  metritis  proper  and 
its  various  forms.  If  we  consult  other  authors,  we  shaU  find  a 
varied  classification  according  to  point  of  departure  taken  in  each 
system  :  the  progress,  into  acute  and  chi'onic  ;  the  seat,  corporeal, 
cerAdcal,  endo-,  parenchymatous,  and  meso-  metritis ;  the  etiology, 
puerperal,  post-puerperal,  blennorrhagic,  traumatic,  diathetic,  etc. ; 
pathological  anatomy,  granular,  fungous,  and  ulcerative  metritis. 


Metritis. — Pathological  Anatomy. — JStiology. 


79 


All  these  classifications  have  one  fault,  they  are  artificial.  They 
are  based  on  a  single  characteristic,  arbitrarily  chosen,  and  one 
that  is  not  of  as  great  value  as  others  which  are  made  subordinate 
to  it.  To  approach  as  nearly  as  possible  to  a  natural  classification 
there  is  only  one  guide  to  follow,  that  is  the  clinical  one.  I  propose, 
then,  to  classify  the  metrites  according  to  their  dominant  clinical 
character,  whether  it  be  drawn  from  the  prorgess,  or  whether  it  be 
the  result  of  the  marked  predominance  of  an  order  of  symptoms. 
We  have  thus  the  following  forms:  1.  Acute  inflammatory;  2. 
Haemorrhagic ;  3.  Catarrhal;  4.  Painful  (chronic).  Only  these 
terms  will  henceforth  have  for  us  a  classifying  value.  We  shall 
employ  indifferently  all  the  other  qualifications  by  giving  them  a 
purely  descriptive  value. 

Pathological  anatomy. — For  methodical  description  of  the 
anatomical  lesions  met  with  in  metritis  it  is  necessary  to  depart 
momentarily  from  the  clinical  classification  and  to  follow  simply  the 
topographical  order,  lesions  of  the  body  and  lesions  of  the  cervix. 


Fig  39 — Mucous  membrane  of  the  body  ot  the  uterus  Noimal  state  (shghtly 
magnified)  (Wyder  )  The  surface  of  the  mucosa  is  to  the  leit,  the  fibres  of  the 
muscular  layer  are  to  the  light 


Fig.  40. — Mucous  membrane  of  the  cervix.     Normal  state  (slightly 
enlarged).     (Wyder.) 


80 


Metritis. — Pathological  Anatomy. — jEtiology. 


Fig.  41. — Section  of  the  normal  mucosa  of  the  body  of  the  uterus,  examined 
under  a  magnifying  power  of  two  hundred  diameters  (Cornil.) 


Fig.  42. — Uterine  mucous  membrane  during  menstruation.     Normal  state  (Wyder). 

Lesions  of  the  body. — lu  most  works  they  divide  metritis,  acute  and 
clii'onic,  iuto  parenchymatous  and  endo-  metritis  and  the  anatomo- 
pathological  and  clinical  study  follow  this  schematic  classification. 
I  do  not  adopt  it  in  the  clinic ;  nor  shall  I  follow  it  in  the  description 
of  lesions.  I  shall  indicate  as  a  whole  the  lesions  of  all  the  coats  in 
acute  inflammation,  then  then*  lesions  in  chronic  inflammation. 


Metritis. — Pathological  A  natomy. — Mtiology. 


81 


^  Jim r ion. 
B.  Chori.cn 


C2om  cef/ulafuji' 


0  Zcna  exfohatwnis- 


[  Zo2ia  glandulamm  > 


Fig.  43. — Decidua,  normal  state  (Friedlander).     This  figure  is  somewhat  schematic 
for  the  sake  of  clearness.     It  represents  the  decidua  at  the  end  of  pregnancy. 


Fig.  44. — Acute  metritis  (septic).     Slightly  enlarged,     a  b,  surface  of  the 
mucosa ;   under  it  is  the  layer  of  muscular  fasciculi. 


82  Metritis. — Pathohijical  A natoimj. — ^-Etiohgy. 

Acute  metritis. — The  descriptions  which  have  been  given  of  lesions 
of  the  parenchyma  in  acute  metritis  are  almost  all  marred  by  one 
fault :  acute  metritis,  non-puerperal,  not  being  fatal  and  not  justify- 
ing hysterectomy,  the  descriptions  have  been  given  from  the  post- 
mortem findings  in  puerperal  women,  where  the  lesions  of  the 
parenchyma  and  of  the  mucous  membrane  of  the  uterus  were  in  fact 
anything  but  comparable  to  what  should  be  found  in  the  acute  phases 
of  inflammation  of  a  nou-gra^dd  uterus.  It  is  necessary  at  the  start 
to  get  rid  of  these  old  ideas,  among  them  those  which  so  many 
authors  have  laid  down  simply  from  observations  on  puerperal 
women.  We  find  as  notes :  increase  of  volume,  softening  of  the 
tissues,  deep-red  color  studded  with  yeUow  points,  dilatation  of  the 
vessels,  exfoliation  of  the  mucosa.  In  order  to  complete  the  cycle 
of  acute  inflammation,  there  remains  suppuration ;  here  again  the 
authors  adopt  blindly  a  certain  number  of  old  observations  which 
are  all  open  to  criticism  and  capable  of  a  different  interpretation. 
The  assumed  abcesses  of  the  walls  of  the  uterus  are  :  1.  Purulent 
collections  contiguous  to  that  organ,  as  is  so  frequently  observed 
in  pyosalpingitis.  2.  Suppuration  of  gangrenous  myomata, 
which  has  no  relation  to  metritis.  Certainly  if  they  mean  to  say 
that  suppuration  of  the  muscular  coat  of  the  uterus  is  possible,  we 
should  agree  with  them,  but  we  can  denj^  that  it  suppurates  in 
metritis. 

What  we  know  most  precisely  of  the  acute  lesions  of  the  mucosa 
is  revealed  by  the  examination  of  the  membranes  of  membranous 
dysmenorrhoea.  The  mucous  membrane  is  soft  and  thick ;  under 
the  microscope  we  see  that  the  glands  are  not  altered,  but  that  the 
inter-glandular  tissue  undergoes  particular  metamorphosis.  The 
cells  appear  in  much  greater  mumber  than  commonly  and  they  are 
so  pressed  against  one  another  that  there  remains  but  little  space 
for  the  homogenous  inter-cellular  substance.  They  preserve  their 
normal  size  and  differ  by  that,  and  by  the  small  quantity  of  their 
protoplasm,  from  the  cells  of  the  decidua.  Finally,  it  is  an  acute 
interstitial  inflammation  (Fig.  45). 

Chronic  Metritis. — -The  lesions  of  the  parenchyma  in  chronic 
metritis  are  above  all  characterized  by  hypertrophy  of  the  con- 
nective tissue,  causing,  generally,  an  increase  in  the  volume  of  the 
organ,  which,  however,  does  not  ordinarily  exceed  the  size  of  a  fist. 
This  increase  in  size  may  be  entirely  wanting  and  be  replaced  in 
inveterate  cases  by  a  diminution  of  the  body  of  the  organ.  We 
admit,  somewhat  theoretically,  according  to  Scanzoni,  two  periods 
in  the  morbid  evolution :  infiltration  and  induration.  The  first 
period  corresponds  to  an  active  or  passive  congestion  of  the  organ, 
from  which  arises  the  areolar  aspect  that  its  walls,  traversed  by 
dilated  vessels,  present.  There  are  a  great  number  of  embryonic 
nuclei  all  tlu'ough  the  thickness  of  the  tissues,  the  predominant 


Metritis .  — Pathological  A natoviy.  — ^Etiology. 


83 


histological  lesion  is  hyperplasia  of  the  connective  tissue.  Authors 
are  not  agreed  as  to  whether  the  muscular  tissue  takes  part  in  the 
hypertrophy.  Finn  admits  this  hypertrophy  and  denies  the  im- 
portance of  the  fatty  degeneration  that  is  occasionally  described. 
De  Sinety,  on  a  section  he  has  studied,  has  found  considerable 
dilatation  of  the  normal  lymphatic  spaces,  an  hyperplasia  of  the 
circumvascular  connective  tissue  diminishing  in  places  the  calibre 
of  the  vessels,  giving  place  to  a  sort  of  special  sclerosis.  The 
muscular  tissue  does  not  seem  affected.  When  the  uterine  pa- 
renchyma has  thus  been  altered  by  a  profound  inflammatory  pro- 
cess of  long  duration,  it  is  rare  that  there  are  not  at  the  same  time 
traces  of  perimetritis,  adhesions  in  Douglas'  cul-de-sac  giving 
rise  to  deviation  of  the  organs,  traces  of  salpingitis,  perisalpingitis 
and  periovaritis.  The  uterine  mucosa  is  also  always  more  or  less 
diseased. 


Fig.  45  — Acute  endometritis.     Membranous  dysmenorrhoea  (highly  magnified). 
(Wyder.) 

In  many  cases  of  endometritis  of  the  body  and  cervix,  inde- 
pendent of  parturition,  or  in  aged  women  who  have  had  children  a 
long  time  before,  Cornil  has  seen  an  hypertrophy  of  the  uterine 
wall  due,  above  all,  to  the  new  formation  of  connective  tissue  situ- 
ated between  the  muscular  fasciculi.  Most  often  the  fibrous 
bundles  examined  by  the  naked  eye  are  reddish,  and  are  crossed 
by  a  series  of  bridges  or  of  opaque  lines,  which  are  the  thickened 
and  sclerosed  arterioles  in  artheromatous  degeneration-  When 
they  are  observed  under  the  microscope  we  note  a  considerable 


84 


Metritis. — Patlwlogical  Anatomy. — Etiology. 


thickening  of  the  wall  of  the  vessels  by  an  increase  of  elastic  ele- 
ments, which  show  at  the  same  time  cells  in  fatty  degeneration. 
The  sclerosis  of  the  connective  tissue  is  accompanied  in  such  cases 
by  that  of  the  arterial  and  venous  coats.  There  is  no  cicatricial 
retraction  of  the  connective  tissue  but,  on  the  contrary,  permanent 
augmentation  of  its  volume.  The  microscopical  and  histological 
lesions  of  the  mucosa  of  the  chi-onically-inflammed  utems  are  to- 
day perfectly  known,  thanks  to  the  operations  which  allow  numerous 
specimens  of  this  lesion  to  be  studied  in  a  fresh  state. 


Fig.  46,~Chronic  metritis,  a  a,  muscular  coat,  with  some  fasciculi  of  inodular 
tissue  to  the  left;  b  b,  connective  tissue;  ^  c,  vessels  with  thickened  walls;  d, 
lymphatic  space. 

I  cannot  better  describe  the  habitual  aspect  of  a  uterine  mucous 
membrane  thus  altered  than  by  quoting  verbatim  the  statement 
wliich  Professor  Cornil  has  made  in  his  remarkable  lectures  recently 
published :  "  The  mucosa,"  he  says,  "  has  not  the  whitish  appear- 
ance, the  smooth  surface  and  special  stiffness  which  it  presents  in 
the  normal  state.  The  surface  is  uneven,  it  is  swollen,  soft,  pulpy, 
resembling  in  its  consistence  and  aspect  currant  jelly ;  the  color  is 
sometimes  a  little  deeper,  and  it  has  then  the  appearance  of  a 
layer  of  blood  transformed  into  blackened  soft  clots.  This  flabby 
layer,  formed  by  the  inflamed  mucous  membrane,  is  easily  dis- 
placed by  the  scalpel,  as  if  one  had  to  do  with  a  softened  tissue. 
It  is  easily  removed  and  torn  by  slight  traction.  An  intense 
congestion  is  found  in  all  the  thickness  of  the  uterine  wall,  in  the  ■ 
interstices  of  the  muscular  fibers  ;  but  it  reaches  its  maximum  at 
the  deep  surface  of  the  mucous  membrane,  where  it  is  extremely 
pronounced.     If  a  clean  section  of  the  mucous  membrane  is  made 


Metritis. — Pathological  Anatomy. — Etiology.  85 

with  a  very  sharp  knife  and  the  ciit  surface  is  observed,  it  is  very 
difficult  to  distinguish  the  mucous  membrane  from  the  muscle,  the 
two  having  an  almost  analogous  appearance.  The  difference  is 
always  found  by  tearing  softly  the  uterine  surface  with  a  curette  ; 
the  mucosa  is  removed,  while  the  muscular  tissue  resists  the  action 
of  the  instrument.  This  is  the  advantage  of  curetting  the  mucous 
membrane,  for  the  curette  cannot  penetrate  the  muscular  tissue 
itself  unless  the  latter  is  very  much  softened  by  inflammation, 
which  is  very  rarely  the  case. 

When  a  section  of  it  has  been  hardened  in  alcohol  in  order  to  fix 
the  parts,  and  sections  are  made,  the  mucosa  appears  considerably 
thickened.  When  the  sections  have  been  stained  withpicro-carmine 
the  thickening  of  the  mucous  membrane  is  clearly  apparent  to  the 
naked  eye.  It  has  a  slightly  yellowish  color,  by  which  it  differs 
from  the  muscular  layer,  which  is  red.  It  is,  besides,  more  trans- 
parent, especially  the  deep  layers,  due  to  the  microscopic  openings 
caused  by  the  glandular  tubes.  To  appreciate  these  details  with 
the  naked  eye,  it  is  sufficient  to  look  at  the  section  colored  with 
pico-carmine  by  daylight.  It  is  thus  shown  that  the  mucous  mem- 
brane attains  a  thickness  of  two,  three,  four,  five  millimetres, 
sometimes  even  one  centimetre,  while  in  the  normal  state  it  is  only 
one  millimetre.  Its  surface,  examined  in  the  sections,  in  place  of 
being  smooth  has  become  fungous,  and  presents  rounded  pro- 
jections and  smooth  depressions.  The  pathological  vegetations  of 
the  surface  have  received  the  name  of  villosities,  villous  processes, 
fungosities,  vegetations,  and  the  disease  has  thus  been  called  vil- 
lous, fungous,  granular  or  vegetating  metritis.  These  vegetations 
are  sometimes  considerable ;  they  have  a  rounded,  elongated  form 
and  sometimes  become  veritable  polypi  which  may  be  sessile  or 
pedunculated.  In  other  cases,  besides  these  new  productions,  small 
cysts  are  seen,  the  size  of  the  head  of  a  pin,  altogether  analogous  to 
the  Nabothian  glands,  which  are  so  common  in  the  cervical  cavity 
and  on  the  surface  of  the  mucosa  of  the  cervix  and  which  have  the 
same  glandular  origin.  They  always  dift'er  from  the  latter  in  the 
character  of  their  fluid  contents.  Their  contents  differ  especially 
in  being  more  liquid,  more  serous,  less  consistent,  less  gelatinous 
than  in  the  Nabothian  glands  of  the  cer-^dx.  The  small  glandular 
cysts  of  the  body  of  the  uterus  are  observed  oftener  in  the  internal 
metritis  of  aged  women.  Such  is  the  microscopic  aspect  of  the 
chronically  inflamed  uterus." 

In  the  histological  point  of  view  there  exist  three  types,  often  very 
distinct  in  some  sections,  although  combined  in  others.  I  shall 
follow  in  this  discription  the  recent  work  of  Wyder. 

Interstitial  endometritis  (chronic).  —  The  inter-glandular  tissue, 
which  we  have  seen  so  gorged  with  cells  in  the  acute  form  that  it 
then  almost  resembles  granulation  tissue,  is  transformed  into  a 


86 


Metritis. — Pathological  A natomy. — JStiology. 


true  cicatricial  tissue  in  which  the  number  of  cellular  elements 
predominate  more  and  more.  The  glands  suffer  the  consequences 
of  tliis  morbid  process,  they  are  either  compressed  in  parts  and 
transformed  into  cysts,  or  compressed  in  their  whole  extent  and 
more  or  less  atrophied,  so  that,  in  some  cases,  only  very  few  glands 
are  found  in  the  middle  of  the  coimective  tissue  (Fig.  47),  and  in 


Fig.  47. — Interstitial  endometritis;   partial  atrophy  of  the  glands  (Wyder). 

others,  cysts  are  produced  (Fig.  48  A)  or  even  a  complete  de- 
struction of  the  glands  (Fig.  48  B).  In  cases  of  atrophy  so  pro- 
nounced the  muscular  tissue  is  lined  with  only  a  thin  layer  of 
sclerosed  conuectiA'e  tissue,  covered  with  ej)ithelium.  We  can  see 
them  (Fig.  47)  under  the  surface,  still  covered  ^dth  the  pavement 
epithelium,  some  fibrous  lamellne  which  traverse  the  mucous  mem- 
brane, anastomosing  and  forming  meshes,  filled  in  general  with 
homogeneous  substances,  although  in  its  depths  they  are  filled  with 
round  cells  much  serrated.  Near  the  surface  the  inter-glandular 
tissue  is  more  regular.  It  is  composed  of  a  series  of  layers  of 
fusiform  cells  with  elongations  between  them.  The  section  con- 
tains but  very  few  glands.  At  many  points  cystic  canities  are  seen 
(Fig.  48),  cubical  epithelium,  and  surrounded  by  bundles  of  con- 
nective tissue  with  fusiform  cells.  At  other  points  there  is  com- 
plete absence  of  glands,  and  the  mucosa  is  represented  by  a 
homogeneous  connective  tissue,  poor  in  cells  and  stronglj''  undu- 
lating, which,  by  the  clearness  of  its  outline,  resembles  the  muscular 
layer.     Near  its  surface  this  mucous  membrane  is  partly  smooth 


Metritis .  — Paiholoc/ical  A natomy .  — AStioloyy . 


87 


and  partly  covered  with  large  and  flat  villosities.     There  are  all  the 
signs  of  an  advanced  sclerosis  of  the  connective  tissue. 


Fig.  .48. — Interstitial  endometritis;   total  atrophy  of  the  glands  (Wyder).    A,  cystic 
dilatation,  last  glandular  vestige  ;  B,  total  disappearance  of  the  glands. 

Chronic  glandular  endometritis.— Huge,  and  after  him,  Wyder, 
recognized  two  forms  of  glandular  endometritis,  one  of  hypertrophic 
form,  one  of  hyperplastic.  In  the  first,  the  proliferation  of  the 
epithelium  takes  place  without  multiplication  of  the  glands  them- 
selves. In  place  of  being  represented  by  a  more  or  less  straight 
tube,  the  glands  have  then  an  irregular  form  and  are  often  twisted 
into  a  spiral  form.  In  the  hyperplastic  form  there  is  a  multi- 
plication of  the  glands.  Figure  49  represents  a  mixed  form  of 
hypertrophy  and  hyperplasia  combined,  less  rare  than  is  believed. 
The  glandular  tissue  is  absolutely  normal,  as  to  structure,  but  the 
glands  are  much  distorted  or  present  lateral  prolongations. 

PolyjMid  endometritis  (chronic). — Tliis  is  characterized,  to  the 
naked  eye,  by  the  enormous  development  of  the  mucosa,  which  has 
a  fungous  appearance  and  which  may  sometimes  be  filled  with  soft 
polypoid  productions.  It  is,  from  an  histological  point  of  view,  a 
mixed  form,  at  once  interstitial  and  glandular,,  with  marked  cystic 
degeneration.  At  the  surface,  with  the  naked  eye,  are  seen  small 
vesicles  of  one  millimetre  in  diameter,  transparent  and  a  little  pro- 
jecting. With  the  microscope  (Fig.  50)  these  cysts  evidently 
proceed  from  the  degenerated  glands,  covered  with  cubical  epi- 
thelium.    They  are  separated  by  bundles  of  connective  tissue.     In 


88  Metritis. — Patholo(jical  Anatomy. — Etiology. 

the  superficial  part  of  the  mucosa,  dilated  glands  are  found.  In 
the  deep  parts  they  are  often  normal  but  tortuous,  and  lying  some- 
times paraUed  to  the  surface  of  the  muscular  fibers,  sometimes  ob- 
Hquely.  The  glandular  culs-de-sac  oftener  pass  the  deep  limit  of  the 
mucosa  and  force  themselves  between  the  adjacent  muscular  fibers, 
according  to  Cornil  (Fig.  49).  It  is  there  a  remarkable  example  of 
that  which  in  old  general  anatomy  is  called  glandular  heterotopia, 
showing  what  can  be  produced  under  the  influence  of  simple  inflam- 
mation mthout  malign  influence.  In  this  encroachment  of  muscu- 
lar tissue,  the  glands  are  accompanied  with  a  certain  quantity  of 
comaective  tissue  which  surrounds  them.  The  inter-glandular 
tissue  is  very  rich  in  vessels.  At  the  points  corresponding  to 
glandular  dilatations  it  sometimes  encloses  numerous  fusifrom  ceUs 


Fig.  49. — Glandular  endometritis  of  the  body  ol  the  uterus  (Wyder). 
Slightly  magnified. 

with  prolongations  which  give  them  a  striated  appearance,  some- 
times it  assumes  the  form  of  fibrous  tissue  relatively  poor  in 
cellular  elements ;  it  is  this  which  is  observed  in  the  immediate 
neighborhood  of  the  vessels.  Deeply,  and  around  the  intact  glands, 
as  well  as  between  the  cysts,  the  inter-glandular  tissue  is  replaced 
by  a  homogenous  substance,  rich  in  round  cells,  pressed  one  against 
the  other  (Fig.  50).  Finally,  there  is  an  lustological  variety  of 
endometritis  which  surely  does  not  merit  elevation  to  the  dignity  of 
a  special  form,  but  which  it  is  useful  to  specify — that  is,  post-abortum 
endomrtritis.  According  to  Schi-oeder,  it  is  invariably  interstitial 
endometritis  that  is  observed  after  abortion;  the  glands  become 


Metritis. — Pathological  Anatomy. — .Etiology.  89 

diseased  to  their  whole  length.  But  what  gives  a  characteristic 
aspect  to  this  anatomical  picture,  is  the  incomplete  or  defective 
involution  of  the  true  decidua.  This  undergoes  regressive  meta- 
morphosis so  incompletely,  that  more  or  less  extended  islets  of 
membrane  are  seen  to  exist,  around  which  is  produced  a  very  active 


Fig.  51. — ^nAoraAriWs,  post-adori-u?n  showing  the  islets  of  the  decidua, 
around  which  cellular  proliferation  is  taking  place. 

proliferation  of  small  cells  (Fig.  51).  These  inflammatory  modi- 
fications, says  Shroeder,  differ  essentially  from  placental  retentions, 
which  are  often  desiganted  wrongly  by  the  name  of  post-abortwm 
endometritis,  which  are  only  a  post-ahortum  hemorrhagic  accident 
due  to  the  incomplete  contraction  of  the  uterus  and  its  vessels. 


90  Metritis. — Pathological  Anatomy. — -.Etiolofiij. 

Lesions  of  the  cervix.  —  It  is  not  anatomically  exact  to  say  that 
there  are  distinct  cervical  and  corporal  metritis,  for  the  inde- 
pendence of  these  two  portions  of  the  uterus  is  never  complete. 
Most  frequently  the  lesions  are  contemporary  and  evolved  together. 
However,  it  is  possihle  that  the  inflammation  is  localized  more 
especially  in  one  or  the  other  of  these  parts.  Cervical  metritis 
ordinarily  predominates,  for  this  part  is  more  exposed  to  the  ex- 
citing causes.  If  it  is  the  mucosa  that  is  suddenly  attacked  and 
diseased,  its  alterations  are  quickly  propagated  to  the  musculo- 
iibrous  tissue,  and  a  true  parenchymatous  cervical  metritis  suc- 
ceeds to  all  inflammations  of  the  cervix  of  some  duration.  Cornil 
explicitly  describes  these  lesions  of  parenchymatous  metritis, 
which  may  be  partial.  For  example,  these  lesions  are  sometimes 
confined  in  the  cervix  to  the  ectropion  of  this  organ,  caused,  not 
only  by  the  thickening  of  the  cervical  mucosa,  turned  outward  into 
the  vagina  and  infiltrated,  but  also  by  the  thickening  of  the  con- 
nective tissue  situated  uiider  the  mucous  membrane  and  between 
the  muscular  fasciculi.  In  this  connective  tissue,  the  lesions  of 
recent  inflammation  are  often  found,  in  the  thickening  of  the 
fasciculi  and  in  the  interposition  of  flat  cells.  The  cervix  uteri  in 
the  antritis,  may  offer  special  and  very  diverse  lesions :  lacera- 
tions, ectropion  of  the  mucosa,  hypertrophy,  congestion,  varicosity, 
granulations,  folliculitis,  erosions,  ulcerations,  cysts  of  Nabothian 
glands,  etc.  As  this  portion  of  the  uterus  is  accessible  to  view,  the 
microscopical  description  of  these  lesion  enters  into  the  clinical 
account.  But  it  is  important  to  state  precisely  the  exact  nature  of 
some  of  them  as  made  by  liistological  examination. 

Nabothian  Glands. — Granulations  and  FolUcHHtis. — Nabothian 
glands  are  small  cysts,  granulations  or  folliculitis  are  small  ulcer- 
ations (I  shall  explain  the  value  of  this  word  further  on)  distributed 
on  the  surface  of  the  cervix.  They  both  sometimes  simulate  a  sort 
of  eruption,  according  to  some  authors,  erythema,  eczema,  herpes, 
acne,  or  pemphigus. 

Erosions,  Ulcerations. — The  cervix  may  show,  in  the  neighborhood 
of  the  external  orifice,  a  red  and  roughened  aspect,  without  pro- 
jection or  depression.  This  is  an  erosion,  properly  so-called.  It 
may  be  observed  in  the  case  of  an  acute  vaginitis  with  abundant 
secretion,  or  again  following  the  contact  of  a  foreign  body  (pessary). 
Under  the  microscope  we  find  that  there  has  been  a  simple  sub- 
stitution of  cylindrical  epithelium  for  the  normal  pavement  epi- 
thelium. Fischel  has  shown  that  we  sometimes  find  at  birth,  a 
pseudo  erosion  of  the  mucosa  of  the  cervix,  due  to  the  fact  that  at 
the  external  border  of  the  external  orifice  the  epithelium  is  there 
cylindrical  in  a  certain  external  zone.  Later,  tliis  epithelium 
changes  to  the  pavement  variety,  but  if  it  desquamates  under  any 
influence,  the  primitive  aspect  reappears.     Thus  will  be  created  a 


Metritis. — -Pathological  Anatomy. — ^Etiology.  91 

very  curious  congenital  predisposition  to  erosions.  The  remarks 
'of  Klotz  are  in  keeping  with  this  view;  according  to  this  author 
there  are  women  who  have  erosions  or  ulcerations  from  the  in- 
fluence of  any  very  slight  inflammation,  while  others,  attacked  by 
intense  cervical  catarrh,  never  show  them.  It  seems,  then,  there. 
are  women  especially  predisposed  to  cervical  metritis,  by  a  true 
congenital  idiosyncracy. 

Ulceration  is  the  name  given  to  another  condition.  On  all  the 
circumference  of  the  orifice,  or  only  on  a  part,  exists  an  apparent 
excavations,  generally  circumscribed  by  a  circular  border,  the 
surface  of  which  appears  smooth  and  red,  or  again  velvety  and  even 
villous.  Gynsecologists  have  long  seen  in  this  a  loss  of  substance, 
with  detruction  of  tissue,  from  which  comes  the  name  ulceration, 
ulcerated  cervix,  and  some  of  them  singularly  exaggerate  the 
importance  of  this  lesion.  A  reaction  has  set  in.  Gosselin  first 
had  the  audacity,  great  at  the  period  when  he  formulated  his 
opinion,  to  contend  that  i;lceration  is  not  a  disease  at  all,  but 
only  a  symptom  of  uterine  catarrh.  Tyler  Smith,  and  after  him 
Eosa,  saw  in  this  lesion  only  a  hernia  of  the  mucosa  of  the  interior 
of  the  cervix,  and  according  to  the  expression  of  Eosa,  an  ectropion 
comparable  to  that  of  the  eyelids  when  the  conjunctiva  is  everted  or 
inflamed.  This  author  distinguishes  a  traumatic  or  cicatricial 
ectropion  due  to  laceration  of  the  cervix,  and  inflammatory 
ectropion  due  to  hernia  of  the  cervical  mucosa  It  is  certainly  nec- 
essary to  take  into  account  this  sort  of  decent  of  the  tumified 
intracervical  mucous  membrane  beyond  the  orifice  and  on  the 
external  face  of  the  cervix.  It  may  constitute,  in  cases  of  deep 
lacerations,  the  greater  part  of  the  exposed  surface  of  ulceration. 
But  in  many  cases  the  closed  orifice  of  the  cervix  leaves  projecting 
only  a  thin  strip  of  the  internal  mucosa,  and  as  ulceration  invades 
a  great  part  of  the  convex  surface  of  the  cervix  it  is  absolutely 
necessary  to  recognize  that  there  has  been  an  alteration  of  this 
surface.  What  is  the  exact  nature  of  this  alteration.  Is  the  old 
notion  of  ulceration  exact  and  does  it  represent  an  anatomical 
reality  or  only  an  appearance  ?  The  work  of  Veit  and  Euge  pre- 
sents this  question  in  a  new  light.  These  authors  affirmed  that 
there  is  no  destruction  of  tissue,  but  neoformation.  While  cylin- 
drical epithelium  replaces  the  pavement  epithelium  at  the  ulcerated 
border  of  the  external  surface,  it  produces  juxtaposed  glands  and 
the  inter-glandular  substance  takes  a  palisade-like  appearance,  its 
projections  producing  the  papillary  aspect  of  the  surface.  When 
a  bilateral  lacertion  of  the  cervix  permits  this  glandular  neofor- 
mation to  grow  toward  the  exterior,  it  borders  the  external  orifice 
as  a  cuff  of  crimson  velvet  on  a  sleeve.  At  other  times,  these 
glands  become  cystic  and  form  mammillated  projections  in  the  base 
of  the  ulceration,  which  then  takes  the  follicular  aspect  (more 


92 


Metritis. — Pathological  Anatomy .^jEtiology . 


evident  still  in  a  cut  than  to  direct  inspection)  (Fig.  52  C).  These 
cysts  may  form  masses  detached  from  the  surface  of  the  cervix 
under  the  form  of  mucous  polypi.  These  are  small  reddish  masses, 
semi-transparent  or  \-iolaceous,  more  or  less  freely  pedunculated 
in  the  cavity  or  outside  the  orifice  of  the  mucous  membrane  of  the 
cervix.  When  the  cystic  transformation  of  the  glands  takes  place 
in  the  thickness  of  the  cervical  tissue,  it  may  provoke,  by  pene- 
trating and  dilating  its  substance,  its  elongation  by  follicular  hy- 
pertrophy (Fig.  56  A).  Finally,  glandular  vegetation  and  cystic 
transformation  may  also  take  place  in  the  interior  of  the  half-open 
cervix  and  then  constitute,  in  the  cavity,  sessile  projections  easily 
comparable  to  a  tonsil  (Fig.  56  B). 


F'g- 52  — a  ^,  simple  papiUar)  eiosion,    f,  follicular      Slightly  magnified. 

The  theory  of  Euge  and  Veit,  true  in  the  great  majority  of  cases, 
is  not,  however,  as  absolute  as  these  authors  have  contended.  Fisehel 
has  questioned  their  exclusiveness  and  sho-mi  that  there  is  some- 
times ti-ue  loss  of  substance — ulceration  in  the  proper  sense  of  the 
word.  The  epithelium  is  then  desquamated  and  the  mucous  mem- 
brane is  covered  with  patches  of  inflammatory  granulations  starting 
from  the  papillje.  Doderlein  has  verified  the  fact  of  these  two 
processes,  that  of  pseudo  ulceration  (Euge  and  Veit)  and  that  of  true 
ulceration  (Fisehel). 

Laceration  of  the  cervix  is  the  most  frequent  lesion  after  ac- 
couchement.    It  is  even  observed  after  miscarriage  at  two  months. 


Me tritis .  — Pathological  A natomy .  — Etiology . 


93 


a  time  when  the  elasticity  of  the  ovum  renders  this  lesion  im- 
probable a  ^jrjoj'i,  but  if  the  cervix  is  not  sufficiently  soft  and  dilated 
it  may  be  torn  even  at  this  time.  It  is  almost  always  at  the  first 
accouchement,  according  to  the  statistics  of  Munde,  that  this  lacer- 
ation appears.  It  is  possible,  however,  that  the  cervix,  like  thp 
perinseum  left  intact  by  preceeding  deliveries,  may  be  torn  subse- 
quently.    Although  there  sometimes  does  not  exist  the  least  nick 


"Si    Vi 


"-^  '^^*-^% 


Fig.  53. — Transverse  section  of  the  upper  part  of  the  cervix  (enlarged  twelve 
diameters).  (Cornil.)  The  vacant  central  space  represents  the  cavity  of  the  cervix; 
d  6,  internal  surface  of  the  mucosa  presenting  small  projections,  superficial  glandular 
depressions,  and  deep  depressions;  d,  intermedium  of  the' arior  vita;  g g,  deeply 
situated  glands;  m  m,  muscular  tissue  of  the  uterine  wall. 


94 


Metritis., — Pathological  Anatomy.- — ^Etiology. 


on  the  cervix  of  a  -vvonian  who  has  had  children,  the  frequence  of 
laceration  is  considerable.  Their  pathological  role  has  been  made 
prominent  and  certainly  exaggerated  by  Emmet,  who  has  gone  so 
far  as  to  say  :  "  Half,  at  least,  of  the  uterine  affections  of  women 
who  have  had  children  arise  from  lacerations  of  the  cervix."  PaUen 
estimates  the  proportion  of  such  cases  as  40  per  cent,  Goodell  says 
one-sixth,  Munde,  out  of  two  thousand  five  hundred  women  deUvered, 
found  six  hundred  and  twelve  lacerated  (25  per  cent),  but  two 
hundred  and  eighty  (12  per  cent)  only  being  deep  enough  to  be  able 


mmm 


Fig.  54. — Section  of  the  vaginal  portion  of  the  cervix  in  chronic  inflammation 
(forty  diameters).  ^,  papillse  covered  by  a  single  layer  of  cylindrical  epithelium; 
at  c,  the  epithelium  become  pavementous ;  </,  depression,  at  its  edge  the  pavement 
epithelium  progressively  thickens;  s,  superficial  layer  of  flattened  epithelium;  m, 
thickening  of  the  mucosa; /,  papillae;  //,  connective  tissue ;  z/,  vessels.     (Cornil) 


Fig.  55. — Portion  of  the  mucosa  represented  in  the  preceeding  illustration  (enlarged 
two  hundred  diameters),  a,  superficial  epithelial  layer  formed  by  cylindrical  cells, 
very  much  elongated  (i'i ;  if,  inter-papillary  depression ;  /,  connective  tissue.  (Cornil.) 


Metritis. — Pathological  Anatomy. — Mtiology.  96 


Fig.  56. — Follicular  hypertrophy  of  the  cervix.     A,  internal  surface, 
B,  external  view. 


Fig.  57. — Section  of  a  glandular  polypus  of  the  cervix  (sixty  diameters).  (Cornil.) 
3  a,  granulations;  ^  i5,  grandular  depressions;  ^^,  culs-de-sac  of  these  glands;  v  v, 
bloodvessels. 

to  have  really  a  pathological  influence.  The  others  were  but  slightly 
troublesome.  The  varieties  and  degrees  of  the  laceration  are  very 
variable ;  they  can  be  distinguished  as  unilateral,  bilateral,  anterior, 
posterior,  stellate.  The  bilateral  laceration  is  the  most  frequent, 
then  comes  the  unilateral,  then  the  stellate,  the  multiple  lacerations, 


96  Metritis. — Patholoc/ical  Anatomy. — Aetiology. 

the  posterior  and  finally  the  anterior.  Unilateral  laceration  is  most 
frequently  found  to  the  left,  no  doubt  because  of  the  predominance 
of  the  left  antero-occipito-iliac  presentation,  the  laceration  of  the 
cervix  taking  place  at  the  situation  of  the  occiput.  When  the 
laceration  has  been  deep  and  has  partially  cicatrized,  we  find  a 
cicatricial  line  along  the  cervix  near  this  point.  Sometimes  we 
find  in  the  vaginal  cul-de-sac,  at  the  base  of  the  broad  ligament,  a 
little,  hard  cicatricial  nut,  which  without  doubt  has  the  same  trau- 
matic origin.  In  the  stellate  laceration,  the  rents  are  generally  not 
so  deep.  Finally,  laceration  has  been  assumed  in  cases  which  in 
reality  have  nothing  to  do  with  it,  those  cases  where  the  cer\ix  is 
gaping,  but  in  which  the  finger  can  detect  no  notches  at  its  border. 
The  advocates  of  the  pathogenic  role  of  lacerations  see  here  a  lacer- 
ation of  the  internal  mucosa  of  the  cervix  entailing  subinvolution 
of  all  the  cervix  and  its  cavity.  According  to  Munde,  this  variety 
should  be  considered  a  subinvolution  of  the  cervix  with  paralyses 
of  the  muscular  fibers  ijroduced  by  these  submucous  ruptures. 

For  convenience  of  discription  it  is  proposed  to  distinguish  lacer- 
ation according  to  its  depth,  in  thi'ee  degrees  :  the  first,  which  only 
slightly  impairs  the  cervix ;  the  second,  which  produces  a  tear  to 
half  its  depth;  the  tliird,  which  reaches  to  the  vaginal  cul-de-sac 
and  even  passes  it  (Munde).  It  is  possible  that  the  laceration  may 
not  be  accompanied  by  ulceration  and  that  all  its  surface  may  be 
covered  by  pavement  epithelium  like  the  rest  of  the  cervix.  This 
cicatrization,  Avithout  reunion  of  the  Hps,  is  particularly  observed 
after  surgical  incisions  followed  by  rigorous  antiseptic  treatment. 
When  it  occurs  after  confinement  we  may  conclude  that  the  lacer- 
ation has  escaped  all  infection.  In  the  contrary  case  vilceration  is 
produced.  Then,  the  deeper  the  laceration  the  more  its  lips  are 
everted,  the  more  considerable  is  the  ectropion  of  its  internal  mucous 
membrane.  This  exposure  of  the  mucous  membrane  to  vaginal 
causes  of  irritation,  secretions,  rubbing,  contact  of  the  air,  is,  with- 
out doubt,  a  very  favorable  condition  for  the  perpetuation  of  the 
morbid  processes  which  constitute  so-called  ulceration.  The  papilli- 
form  and  cystic  alterations  may  then  extend  so  far  and  be  so  largely 
spread  on  the  everted  lips  as  to  have  the  appearance  of  a  malignant 
growth.  At  the  same  time  it  produces  in  the  lacerated  cervix  im- 
portant histological  alterations.  In  the  first  place,  the  work  of 
cicatrization  itself,  by  the  retraction  of  inodular  tissue,  may,  in 
cases  of  large  laceration,  produce  serious  consequences.  It  com- 
promises glands  and  causes  their  cystic  degeneration  and  hypertro- 
phy of  tissue  (cystic  hyperplasia).  The  dense  cicatricial  tissue, 
by  implicating  the  nerve  terminations,  will  be,  for  Emmet  and  his 
disciples,  the  origin  of  the  most  varied  nervous  accidents.  Ac- 
cording to  this  gynfecologist,  it  is  especially  the  pressure,  in  the 
superior  angle  of  the  laceration  of  what  is  called  the  cicatricial 


Metritis. — Pathological  Anatomy. — ^Etiology.  97 

plug,  that  is  "  the  root  of  the  evil."  Another  less  early  lesion  of  the 
cervix  is  eversion  of  its  lips.  The  principal  cause  of  this  lies  in 
traction  exercised  by  the  insertions  of  the  vagina  on  the  divided 
cervix ;  it  pushes  to  the  extreme  the  ectropion  of  the  mucosa  and  is 
so  much  the  more  marked  as  the  membrane  becomes  more  diseased. 
Finally,  a  third  consequence  of  the  laceration  is  the  partial  arrest 
of  involution,  from  which  comes  passive  congestion,  catarrh,  etc. 

Pathogeny. — In  the  same  way  as  I  have  united  in  one  paragraph 
the  study  of  anatomy  and  pathology,  I  shall  present  at  a  glance  the 
causes,  avoiding  thus  numerous  and  useless  repetitions.  From  a 
pathogenetic  point  of  view,  we  may  say  that  all  inflammations  of 
the  uterus  are  certainly  of  infectious  origin.  Eecent  researches 
confirm  this.  First  of  all  this  fact  appears  beyond  doubt  for  me- 
tritis of  blennorrhagic  origin.  Stenschneider,  in  his  studies  on  the 
seat  of  gonorrhoeal  infection  in  women,  has  demonstrated  that  long 
after  the  gonococci  have  disappeared  from  the  urethra  they  are 
found  in  the  cervix  or  body  of  the  uterus,  the  mucous  membranes  - 
of  which  are  infinitely  more  favorable  to  their  development  than 
the  mucosa  of  the  vagina ;  in  which  the  unfavorable  conditions  are 
afforded  by  the  thick  pavement  covering,  the  acidity  of  its  secretions 
and  the  vital  concurrence  of  the  numberless  bacteria  which  normally 
inhabit  this  cavity.  The  same  direct  demonstration  has  lately 
been  accomplish  in  ease  of  the  micro-organisms  of  post-puerperal 
endometritis.  Goenner  (of  Bale)  has  found  streptococci  easily 
cultivated  in  cases  of  puerperal  fever.  Doderlein,  more  recently, 
has  collected  the  lochia,  with  rigid  precaution,  in  the  uterus  itself. 
The  result  of  these  researches  has  been  that  following  normal  con- 
finements, when  the  temperature  does  not  exceed  38°  C,  there  are 
no  germs.  When  there  is  fever,  on  the  contrary,  bacilli  and  cocci 
are  found,  which,  when  the  temperature  falls,  are  exterminated  by 
the  more  abundant  and  purulent  secretions.  The  sequellge  of 
pathological  confinements  (and  without  doubt  also  of  consecutive 
metritis)  are  then  due  to  infection  by  a  pathogenetic  microbe  — 
the  streptococcus  pyogenes.  Doderlein  thinks  that  these  germs  are 
carried  from  the  vagina  into  the  uterus  by  the  exploring  finger  or 
instrument.  It  is  then  well  established  that  in  septic  metritis,  or 
better  in  infection  of  the  uterine  mucosa  that  may  follow  con- 
finement or  abortion,  the  origin  of  these  accidents  is  in  a  prolifer- 
ation of  pathogenic  microbes  and  metritis,  properly  so-called,  which 
persists  after  the  puerperal  state,  is  due  to  the  persistence  of  these 
germs. 

A  more  disputed  question  is  this.  What  is  the  origin  of  these 
microbes'?  Do  they  always  come  from  the  exterior,  or  do  they 
come  from  the  interior  ?  Is  there,  in  other  wor&s,  hetero-infection, 
or  auto-infection  ?  Hetero-infection,  which  is  also  called  infection 
by  contact  (Kaltenbach)  or  exogenous  infection  (Fehling),  is  much 


98  Metritis. — Pathohfjical  Anatomy. — ^Etiology. 

the  most  frequent.  In  spite  of  all  antiseptic  precautions,  the  ex- 
ploring finger  may  be  the  carrier  of  genus.  In  a  healthy  puerpual 
woman,  the  vagina  ought  to  be  considered  aseptic.  There  ai'e  no 
germs  in  the  normal  lochia.  There  are  never  any  in  the  superior 
part  of  the  vagina,  immediately  after  confinement.  Yon  Ott  at- 
tributes this  fact  to  the  effect  of  irrigation  by  the  liquor  amuii  and 
to  the  friction  of  the  foetal  body  against  the  stretched  vaginal  walls. 
Then,  if  all  is  well,  without  retention  of  debris,  without  accumu- 
lation of  clots  by  atony  of  the  uterus,  without  premature  ruptm-e 
of  the  membranes  preventing  the  physiological  in-igation  of  the 
genital  canal,  there  is  no  chance  of  infection.  This  esijlains  the 
happy  termination  of  so  many  confinements  accomplished  without 
precautions.  Nature,  one  may  say,  has  provided  for  the  aseptic 
accomplishment  of  child-birth.  It  is  then  necessary  to  refrain,  as 
much  as  possible,  fi'om  examinations  and  manipulations  iu  simple 
cases. 

There  is  nothing  specific,  so  to  speak,  in  microbean  infection  of 
the  utems.  It  is  well  known  to-day,  that  it  is  the  same  microbe, 
the  streptococcus  pyogenes,  which  causes  aU  the  lesions  of  confine- 
ment, and  that  produces  erysipelas  and  phlegmon.  Puei-peral  in- 
fection of  the  uteiTis,  so  frequently  the  beginning  of  consecutive 
metritis,  may  then  be  provoked  by  pathogenic  germs  coming  from 
the  most  diverse  sources. 

The  researches  of  Winter  present  the  question  in  a  new  light. 
They  lead  to  the  conclusion  that,  in  the  genitalia  of  women,  there  is 
a  danyerous  zone,  rich  in  micro-organisms.  Xot  only  do  the  vagina 
and  the  cervix  contain  germs  in  abundance,  but  in  half  the  cases 
"Winter  has  found  pathogenic  organisms,  namely :  tlu'ee  species  of 
staphylococci  {Si.  jjyogencs  albiis,  aureus,  citrens)  and  many  kinds  of 
streptococci.  This  fact  has  a  vital  importance,  for  it  establishes 
the  possibihty  of  auto-mfection.  We  could  not  comprehend  why  it 
does  not  take  place  oftener  (especially  during  confinement  when  the 
germs  multiply)  if  the  inoculations  made  by  Winter  ^^^th  culture 
thus  obtained,  did  not  show  at  the  same  time  tliis  curious  fact,  that 
these  staphylococci,  domesticated,  so  to  speak,  in  the  genital  pas- 
sages have  lost  their  virulence.  This  is,  then,  an  example  of  spon- 
taneous attenuation  which  is  most  remarkable  and  most  foi+unate. 
But  it  is  very  probable  that  the  virulence  can  be  restored  very  quickly 
in  certain  favorable  conditions,  as,  for  example,  the  presence  of 
organic  detritus.  Thus  can  be  seen  the  extreme  danger  which  re- 
sults from  abortion,  when  pieces  of  the  ovum  remain  in  the  cenix. 
Infection  of  the  uteras  then  takes  place.  Likewise  we  see  how 
dangerous  it  is,  without  previous  cleansmg  of  the  genital  canal,  to 
practice  exploration  of  the  cavity  of  the  body  of  the  uterus,  even 
when  the  finger  or  the  sound  is  absolutely  aseptic,  for  they  may 
carry  staphylococci  from  the  cei-vix  into  the  utems.     It  is  at  the 


Metritis. — Pathological  Anatomy. — Etiology.  99 

edge  of  the  uterine  opening  of  the  cemx,  in  fact,  that  the  hmit  of 
what  can  be  called  the  dangerous  zone  is  found. 

Some  mechanical  conditions  favor  the  infection  of  the  uterus.  Thus 
Schultze  believes  that  in  women  with  a  gaping  ATilva,  as  in  mul- 
tiparous  women,  even  without  laceration  of  the  peringeum,  a  sHght 
leucorrhoeal  discharge  is  sufficient  to  serve  as  a  vehicle  for  atmos- 
pheric germs.  Even  when  the  vulva  is  perfectly  closed,  each 
menstural  period  renders  mfection  possible.  Hence,  according  to 
Schultze,  the  necessity  of  protecting  the  vulva  in  such  cases,  with 
a  layer  of  cotton,  which  filters  the  air.  It  is  not,  however,  only  the 
micro-organisms  wliicli  normally  inhabit  the  vagina  and  cervix  that 
catheterization  may  introduce  into  the  uterus.  In  large  cities  we 
live  in  the  midst  of  pathogenetic  germs.  Eiselsberg  found  staphylo- 
coccus pyogenes  aureus  iw  the  wards  of  the  hospital,  Furbringer  has 
shoAvii  their  presence  under  the  nails,  Passet  in  the  urine,  and  the 
same  author  has  found  staphylococcus  pyogenes  albus  in  beef  slightly 
tainted,  etc.  Biondi  has  even  found  them  in  normal  saliva.  It  is 
seen  what  are  the  chances  of  infection,  and  without  the  i-ital  concur- 
rence of  living  tissues  which  defend  themselves  incessantly  against 
them  it  would  be  almost  inevitable.  All  that  disarms  this  defense 
opens  the  door  to  infection.  May  not  this  increase  of  the  harmful 
properties  of  pathogenetic  germs,  dormant  in  the  healthy  genitalia, 
be  caused  by  other  mechanism?  May  not  general  debility,  by 
diminishing  the  life  of  cells,  or  traumatism,  by  suspending  it  through 
an  inhibitory  action,  impedmg  the  phagocytosis,  remove  the  barriers 
which  separate  these  germs  from  the  uterine  cavity  and  maintain 
them  in  a  region  where  they  remain  inoffensive '?  Thus,  perhaps, 
may  be  explained,  the  undoubted  influence  of  diseases  and  notably 
of  eruptive  fevers,  that  of  venereal  excess,  etc.  Finally,  it  seems  that 
the  pathogenic  germs  often  favor  the  development  of  other  germs. 
Thus,  women  affected  with  blennorrhagic  metritis  (gonococcus  of 
Neisser)  are  easily  affected  by  septic  infection  more  or  less  attenu- 
ated, by  staphylococci  or  streptococci  or,  again,  by  the  bacilli  of 
tuberculosis. 

Let  us  pass  now  to  the  etiology,  properly  so-called,  and  study  the 
immediate  causes  of  metritis.  They  may  be  ranged  under  four 
principal  heads,  in  comiection  with :  1.  Menstruation;  2.  Coitus; 
3.  Parturition;  4.  Traumatism. 

1.  Menstruation.  —  Even  the  estabhshment  of  this  function  may 
be  the  cause  of  the  manifestation  of  inflammation  of  the  uterus, 
because  of  the  intense  congestion  produced  at  tlus  time.  This 
is  generally  associated,  to  a  certain  degree,  with  the  influence 
of  malformation  of  the  organ,  provoldng  stasis  of  the  menstrual 
blood,  of  incomplete  development,  of  congenital  antiflexion,  conical 
cervix,  stenosis  of  the  orifice,  or  a  supplementary  cause,  cold,  mas- 
turbation.   To  this  virginal  metritis  corresponds,  at  the  other  end  of 


100  Metritis. — Patliological  Anatomy. — ^Etiology. 

the  genital  life  of  the  woman,  what  can  be  called  metritis  of  the 
menopause.  Here  again,  the  same  predisposing  cause,  an  intense 
congestion,  occurs  and  exposes  to  all  efficient  causes  of  uterine  in- 
flammation. Between  these  two  extreme  periods,  each  menstrual 
period  is  particularly  favorable  to  an  attack  of  metritis  and  any 
over-fatigue,  any  cold,  may  produce  it  if  the  organ  is  deviated,  if  the 
cervix  is  narrowed,  if  there  is  a  deep,  gaping  laceration  left  by  a 
previous  confinement. 

2.  Coitm. — Excess  of  coitus,  especially  if  it  takes  place  dming  a 
period,  or  coincident  to  other  fatigues,  as  that  of  the  wedding  trip, 
may,  independently  of  any  other  cause,  induce  metritis.  But  how 
many  times  gonorrhceal  infection,  more  or  less  uni-eeognized,  plays 
an  equal  part  in  case  of  the  newly  mamed  !  How  many  husbands 
who  believe  themselves  totally  cm^ed  and  do  not  attribute  any  im- 
portance to  a  slight  m-ethi-al  oozing,  infect,  if  not  the  vagina  or 
urethi'a,  at  least  the  cervix,  the  uterine  cavity  and  even  the  tubes  of 
yomig  women!  Gonorrhceal  infection  may  remain  latent  a  long 
time  in  women,  attenuated  and  localized  in  the  cer^ax.  It  is  often 
only  under  the  influence  of  an  untimely  exploration,  an  abortion  or 
confinement,  actmg  as  an  occasional  cause,  that  the  infection  gains 
the  body  of  the  uterus  and  sometimes  even  passes  it.  Noggerath 
believes  that  among  women  affected  by  gonorrhoea,  confinement  is 
followed  by  endometritis  and  perimetritis  in  the  proportion  of  75  per 
cent.  If  the  word  "perimetritis"  were  replaced  by  "salpingitis,"  I 
would  think  this  statement  much  exaggerated.  It  is  also,  without 
doubt,  to  this  cause,  much  more  than  to  the  traumatism  of  the  fre- 
quent coitus,  that  the  meti-itis  of  prostitutes  must  be  attributed. 
Later,  sterility  ensues  fi'om  the  extentson  of  the  inflammation  to  the 
tubes,  which  ai-e  quickly  obliterated. 

3.  Parturitioii. — This  is  much  the  most  frequent  cause.  After 
normal  confinement,  abortion,  spontaneous  or  provoked,  unknown 
or  recognized,  the  uteras  is  in  a  special  state  of  hj^jei-plasia  and 
congestion  which  demands,  for  its  progi-essive  resolution,  special 
hygienic  conditions.  Now,  these  conditions  are  very  frequently 
neglected,  either  by  carelessness  in  the  upper  classes  or  under  the 
influence  of  necessity  in  the  working  classes.  It  is  not  very  long 
since  the  most  renowned  accouchem-s  considered  a  rest  of  fifteen  or 
twenty  days  as  sufficient.  Guerin  very  justly  opposes  this  fixed 
iTile.  He  advises  waiting  at  least  eight  days  after  the  first  ijeriod 
before  permitting  the  patient  to  leave  her  bed,  only  at  the  end  of 
this  time  has  the  uterus  regained  its  normal  size.  Without  that 
post-puerperal  engorgement  ensues,  which  is  nothing  but  the  post- 
puerperal  metritis  of  Chomel,  the  arrest  of  involution  of  Simpson, 
chi'onic  metritis  or  infarctus  uteri  of  others  (catarrhal  metritis  and 
painful  metritis).  It  is  especially  when  the  confinement  has  not 
been  normal,  when  there  have  been  particular  difficulties  in  the 


Metritis. — Pathological  Anatomy. — ^Etiology.  101 

delivery,  when  the  placental  debris  has  been  retained  for  a  longer 
or  shorter  time  in  the  uterine  cavity,  that  it  is  followed  by  inflam- 
mation. One  cannot  doubt,  then,  that  there  has  been  true  local 
infection  and  if  a  rigorous  antiseptic  treatment  is  not  instituted  in 
a  precise  manner  (intrauterine  injections,  curetting,  etc.),  there 
is  danger  that  this  infection,  at  first  acute,  will  be  perpetuated  in  a 
chronic  form.  The  same  remarks  apply  to  abortions  in  which  there 
are  so  frequently  seen  debris  of  membranes,  sometimes  almost  im- 
perceptible, remaining  grafted  on  the  uterine  mucosa  and  becoming 
so  many  centers  of  infection. 

A  peculiarity  to  which  a  considerable  influence  has  lately  been 
attributed,  is  the  effect  of  lacerations  of  the  cervix  on  the  establish- 
ment and  the  duration  of  metritis.  Among  the  numerous  con- 
sequences imputed  to  it  are  :  retardation  of  the  normal  involution  of 
the  uterus  after  confinement ;  then  hyperplasia,  sclerosis  and  com- 
pression of  the  nerve  filaments ;  congestion  and  even  inflammation  of 
the  ovaries ;  parametritis ;  extension  to  the  rest  of  the  cervix  of  the 
sclerosis  arising  in  the  cicatrice ;  compresion  of  the  glands  and  of 
nerves ;  formation  of  cysts  and  the  production  of  reflex  neuralgias 
and  neuroses ;  ectropion  and  uiflammation  of  the  cervical  mucosa, 
on  account  of  the  frictions  to  wliieh  it  is  exposed ;  finally,  tendency 
to  retroversion  and  prolapsus  of  the  uterus.  This  is  not  all.  Munde, 
Olshausen,  Hegar  and  Kaltenbach,  consider  old  lacerations  as  a 
frequent  cause  of  habitual  abortions,  and  BreisKy  held  that  it  pre- 
disposes to  cancer  by  constituting  a  locus  minoris  resistantice. 

The  views  of  Emmet  on  the  pathogenetic  role  of  lacerations  have 
been  the  subject  of  much  discussion.  It  is  very  difficult  to  speak 
in  a  categorical  fashion  in  the  midst  of  the  contradictory  opinions. 
It  seems  to  me,  however,  that  the  role  of  laceration  has  been  by 
turns  both  too  much  exalted  and  too  much  neglected.  Something 
analogous  to  this  was  seen  by  a  previous  generation  apropos  of 
deviation  of  the  uterus ;  slight  as  it  might  be,  they  attributed  to  it, 
at  that  time,  almost  all  inflammatory  affections  of  the  uterus 
and  its  appendages.  We  have  returned  to  these  excesses.  It  is 
generally  agreed  to  admit  now  that  if  changes  of  position  are  suf- 
ficient of  themselves  to  produce  reflex  nervous  phenomena,  they  are 
powerless  to  prodiice  metritis,  though  they  certainly  predispose  to 
it  and  help  to  keep  it  up.  It  is  here,  without  doubt,  that  the  role 
of  lacerations  is  also  limited  in  the  genesis  of  morbid  reflexes  (pre- 
dispositions) and  catarrhs  of  the  cervix.  But  at  the  same  time 
as  there  exist  uterine  retroversions  without  morbid  symptoms,  so 
there  are  very  many  cases  of  laceration  without  metritis ;  scarcely 
any,  except  the  very  deep  lacerations,  reaching  into  the  cellular 
tissue  of  the  cul-de-sac,  or  again,  bilateral  lacerations  with  marked 
etropion,  constitute  a  pathological  condition. 

4.  Traumatism. —  ^he  chronic   contusion  produced  by  a   badly 


102  Metritis. — Pathological  Anatomy. — ^tiolociy. 

applied  pessary,  either  too  large,  or  placed  before  reduction  and 
pressing  too  strongly  against  the  organ,  has  sometimes  given  rise  to 
signs  of  very  acute  metritis,  which  have  disappeared  after  removal  of 
the  mstrament ;  it  is  specially  produced  by  pessaries  having  an  intra- 
uterine stem,  dangerous  agents  when  they  are  not  carefully  watched 
by  the  surgeon.  Finally  aU  operations  whatever,  iu  the  interior  of 
the  genital  canal,  touch,  catheterism,  cauterization,  dilatation, 
iiacision,  may  become  the  starting  point  of  metritis  (compKcated  by 
peri-  and  parametritis)  if  antiseptic  precautions  have  not  been 
observed.  These  accidents,  formerly  very  frequent,  do  not  now 
exist  in  the  practice  of  those  who  conform  to  the  rules  of  antisepsis. 
If  to-day  inflammation  of  the  uterus  follows  violent  procedures 
carried  on  in  its  cavity  (curetting,  enucleation,  morceUement,  etc.), 
this  uiflammation  up  to  a  certain  point  can  be  kept  aseptic  and 
allayed  -n-ithout  leaving  any  permanent  traces.  Vaginal  douches 
too  hot,  or  too  cold,  have  been  condemned.  I  attach  little  importance 
to  this  cause  ;  the  injection  can  be  injurious  only  when  the  nozzle 
is  not  perfectly  clean,  or  if  it  is  forced  in,  in  such  a  manner  as  to 
wound  the  cervix.  It  is  true,  in  eases  of  prolapsus,  that  the  nozzle 
has  sometimes  penetrated  into  the  cervix,  and  the  injection  then 
has  given  rise  to  serious  accidents,  but  that  has  nothuig  to  do 
with  metritis. 

Diverse  causes. — ^Is  it  necessary,  after  the  example  of  numerous 
authors,  to  mention  as  a  cause  for  metritis,  exanthematous  fevers, 
variola,  measles,  scarlatina?  New  observations  in  proof  of  this 
point  do  not  seem  necessary.  What  cannot  be  denied  is  that  the 
female  genitaha  are  particularly  ^iilnerable  in  convalescense  from 
any  disease  which  has  enfeebled  the  whole  organism.  Some  diseases 
(grave  icterus),  some  poisons  (phosphorus),  give  rise  to  acute,  fatty 
degeneration  of  the  uterine  tissiies ;  these  are  only  lesions,  not  dis- 
eases of  the  uterus,  and  metritis  is  not  properly  insisted  on  here. 
The  influence  of  diathesis  has  been  very  much  exaggerated.  It  is, 
I  believe,  a  true  abuse  of  language  to  describe  a  scrofulous,  or  a 
herpetic,  etc.,  metritis,  as  if  they  possess  distinctive  characters.  I 
willingly  grant  that  the  question  of  the  general  condition  and  of  the 
external  relations  play  a  great  part,  if  not  in  the  causation,  at  least 
in  the  persistence  of  these  local  inflammations  and  in  particular  of 
metritis ;  that  in  consequence,  one  should  inquire  carefully  into  the 
general  health  as  bearing  on  the  treatment.  But  this  is  all  that  I 
shall  concede  to  the  doctrine  of  diathesis. 


Symptoms,  Progress  and  Duu/nosis  of  the  Metrites.  103 


CHAPTER  VI. 


SYMPTOMS,  PROGRESS  AND  DIAGNOSIS  OF 
THE  METRITES. 

In  studying  the  diseases  of  the  internal  genital  organs  in  women, 
it  is  impossible  not  to  notice  the  striking  similarity  of  the  rational 
signs  in  each  of  them,  furnished  by  questioning  the  patient.  The 
ensemble  of  these  symptoms  is  well-nigh  common  to  all,  whether  it 
concerns  a  chronic  metritis,  a  catarrhal  endometritis,  or  even  a 
fibroid  tumor,  a  cancer  or  a  salpingitis.  Certainly  I  carniot  go  so 
far  as  to  say  that  they  may  be  absolutely  identical,  but  if  a  certain 
part  of  the  picture  is  more  prominent  in  certain  diseases — the 
haemorrhage  in  fibroids,  the  leucorrhoea  in  cancer,  the  nervous 
troubles  in  displacements  or  diseases  of  the  appendages — it  is  not 
the  less  true  that  the  principle  characters  are  identical.  This  is 
the  idea  which  I  wish  to  express  by  the  phrase,  uterme  syndrome, 
applied  to  this  common  basis.  There  is  great  interest  in  the  matter 
of  clinical  history,  in  the  synthetical  study  thus  proposed.  In 
fact,  when  this  sketch  of  the  symptoms  as  a  whole  has  been  traced, 
there  will  only  remain,  to  complete  each  special  disease  picture,  to 
add  a  few,  touches,  avoiding  thus,  useless  repetitions.  The  study  of 
the  uterine  gi-oup  of  symptoms  naturally  finds  its  place  here,  since 
it  very  nearly  coincides  with  the  ensemble  of  the  rational  signs  of 
metritis.  How  could  it  be  otherwise  when  in  reality  there  is  a 
metritie  element  superadded  in  almost  all  the  other  affections  of  the 
uterus  and  its  appendages  ?  The  principal  of  the  uterine  symptoms 
are :  the  pain,  the  leucorrhoea,  the  dysmenorrhoea,  the  metrorrhagia 
and,  iinally,  the  symptoms  belonging  to  contiguous  viscera  (bladder, 
rectum),  or  to  distant  organs  (digestive  tract,  nervous  system).  We 
will  pass  them  in  review  successively. 

Pain. — This  pain  is  spontaneous  ;  it  is  located  in  the  pelvic  region, 
but  it  is  to  be  noted  that  its  principal  focus  is  not  in  the  same  situ- 
ation as  the  uterus ;  it  is  not  in  the  hypogastric  region  that  women 
suffer  most,  it  is  frequently  in  one  of  the  iliac  regions,  and  especially 
the  left  iliac,  toward  the  ovary.  To  explain  this  fact,  it  appears 
to  me  probable  that  we  can  admit  that  there  is  often  a  slight  salpin- 
gitis (catarrhal)  in  metritie  inflammations.  The  tubes  are,  in  fact, 
simple  prolongations  of  the  uterine  cornua,  these  organs  are  con- 
joined anatomically  and  pathologically.  Who  says  metritis  could 
almost  say  metro-salpingitis,  with  unequal  distribution  of  the  inflam- 
mation ;  preponderance  on  the  part  of  the  uterus,  with  participation 


104  Siimptomn,  Proyreas  and  Diwjiwsls  of  titc  Metrite>>. 

sometimes  feeble,  but  actual,  on  the  part  of  the  tubes.  From  this 
proceeds  the  paiu  in  the  region  of  the  appendages,  wliich  is  rich  in 
nerve  ramifications.  With  regard  to  the  predomiuance  on  the  left 
side  it  is  as  difficult  to  explain  as  the  predominance  of  the  epididy- 
mitis on  this  side.  Another  focus  of  pam  exists  in  the  lumbar  region. 
The  pain  is  augmented  by  fatigue,  by  missteps,  and  the  jolting  of  a 
carriage.  It  may  not  be  immediately  exaggerated  under  these 
mechanical  influences,  the  painful  exacerbation  being  felt  only  at 
the  end  of  some  time.  The  pain  is  dull,  persistent,  di-aggiug,  giving 
rise  to  a  sense  of  weight,  of  fullness  in  the  ijerinaial  region  and  in 
the  pelvis,  it  appears  to  the  patient  as  if  she  had  a  foreign  body  that 
tended  to  escape,  she  feels  her  uteras.  Her  walk,  in  acute  cases, 
is  characteristic ;  in  place  of  seating  herself  carelessly  she  sits  down 
with  caution,  taking  support  from  the  ai'ms  of  the  chair,  for  fear  of 
awakening  her  dormant  pain.  The  paiu  is  exaggerated  by  pressure, 
and  especially  by  palpation  associated  ^ith  digital  examination.  It 
is  easily  perceived,  however,  that  it  is  not  dii-ect  pressure  on  the 
cervix  Avhich  is  painful,  for  this  organ  is  not  sensitive  (except  in 
cases  of  lumbar-abdominal  neuralgia),  but  the  shock  propagated  by 
ballottemeut  of  the  body  of  the  uterus  itself. 

Leucorrhcca  is  a  constant  symptom.  It  may  be  more  or  less 
masked  by  blood,  exaggerated  by-pm-ulent,  sanious  discharge,  etc., 
Init  it  is  always  present.  Leucorrhoea  is  so  important  a  symptom  in 
gynaecology  that  certain  authors  in  early  times  made  a  disease  of  it, 
the  principal  disease  of  the  uterus,  gi'ouping  aromid  it  the  other 
inflammatory  phenomena.  Courty,  himself,  made  of  cei'tain  leucor- 
rlioeas  a  morbid  entity,  an  idiopathic  affection.  Leucorrhoea  is  the 
exaggeration  and  the  alteration  of  physiological  uteriue  and  vaginal 
secretion.  The  uterus  and  vagina  secrete,  in  the  normal  state,  a 
very  small  quantity  of  a  mucous  liquid  which  always  contains 
leucocytes.  It  is  an  oozing  due  to  the  slow  destruction  of  the 
epithelial  covering.  If  it  exceeds  a  certain  degi-ee,  if  it  becomes 
more  abundant  and  punilent,  it  is  abnormal  aud  constitutes  leucor- 
rhoea. It  proceeds  fi-om  two  sources,  fi-om  the  vagina  and  from  the 
uterus.  Vaginal  leucorrhcea,  which  often  exists  alone,  consists  of  a 
very  fluid  discharge,  of  milky  appearance,  only  slightly  stift'erung  the 
Imen ;  in  certain  cases  contains  pus  and  has  a  greenish-yellow  tinge. 
Its  reaction  is  acid.  Leucorrhoea  fi-om  the  body  of  the  uterus  is  of  a 
yelloAA-ish- white  color  aud  but  slightly  viscous.  That  fi-om  the  cervix 
is  gelatinous ;  in  the  normal  state  it  is  transparent,  resembling  the 
white  of  an  egg  and  gi-eatly  stiffens  the  linen.  In  a  pathological 
state  it  is  puiident  and  of  a  gi-eenish-yeUow  color.  Its  reaction  is 
alkahue.  The  leucorrhoeal  flow  is  not  constant,  it  accumulates  in 
the  vagina  and  escapes  in  small  masses  fi'om  time  to  time.  Finally, 
ill  some  cases  tnie  secretory  crises  have  been  observed,  a  large 
quantity  of  liquid  appearing  suddenly  after  some  severe   pains. 


Symptoms,  Progress  and  Diagnosis  of  the  Metrites.  105 

This  has  often  led  to  a  belief  in  an  intermittent  evacuation  of  a 
hydrosalpynx.  But  this  symptom  may  exist  also  in  metritis  with- 
out a  tubal  collection,  as  I  have  observed  several  times.  JProperly 
speaking,  it  is  a  pathological  reflex  hypersecretion.  Some  authors 
have  sought  a  means  of  establishing  the  difference  between  vaginal^ 
leucorrhoea  and  that  from  the  uterus.  Schultze  proposes  the  intro- 
duction of  a  tampon  of  cotton,  which  is  left  against  the  cervix  for 
twenty-four  hours.  On  withdraM-ing  tMs  the  quantity  and  quality 
of  the  uterine  secretions  can  be  recognized.  Leucorrhoea,  may  be 
simply  dependent  upon  some  fault  of  the  general  health,  as  anaemia 
or  chlorosis. 

Metrorrhagia,  Dysmenorrua^a. — ^Menstrual  disturbances  may  be 
observed  m  uterine  affections  but  they  are  not  necessarily  constant. 
Dysmenorrhoea,  or  painful  menstruation,  is  often  observed  in 
metritis,  in  consequence  of  certain  mechanical  obstacles  to  the 
menstrual  flow  (flexions,  narrowness  of  the  cavity  of  the  cervix),  as 
these  obstacles  favor  inflammation.  Amenorrhoea  is  sometimes 
the  consequence  of  the  debility  produced  by  a  long-lasting  metritis. 
Metrorrhagias,  on  the  contrary,  are  certauily  directly  dependent 
upon  metritis,  especially  Avhen  the  mucosa  of  the  body  of  the  uterus 
is  affected  by  an  interstitial  endometritis  (either  primary  or  con- 
secutive to  fibroids  or  cancer).  The  loss  of  blood  may  occur  during 
the  menses,  which  are  then  prolonged,  or  outside  the  catamenial 
period.  In  the  fii'st  case  we  have  menorrhagia;  in  the  second, 
metrorrhagia. 

The  majority  of  metrites  are  generally  an  obstacle  to  conception. 
However,  pregnancy  has  been  observed  even  in  cancer  and  in 
fibroid  tumor,  likewise  in  metritis.  But  in  these  cases  abortion  is 
frequent. 

Symptoms  relating  to  contiguous  organs  and  reflex 
phenomena. — In  all  uterine  affections  we  obseiTe  symptoms  re- 
lating to  the  neighboring  organs  (independently  of  the  phenomena 
of  compression).  The  woman  very  frequently  has  pain  in  iirinating, 
frequent  micturition,  and  even  vesical  tenesmus.  Every  disease  of 
the  uterus  affects  the  bladder,  more  or  less,  and  sometimes  the 
patient  draws  the  attention  of  the  physician  to  the  vesical  phe- 
nomena alone.  As  women  often  suffer  in  defecation,  on  account  of 
the  efforts  that  tliis  act  demands,  communicating  a  disturbance  to 
the  diseased  uterus,  they  accustom  themselves  to  going  mthout  stool 
as  long  as  possible  and  constipation  becomes  habitual. 

Uterine  dyspepsia.  —  There  is  no  function  on  wliich  uterine 
affections  react  with  more  constancy  than  digestion.  The  want  of 
recognition  of  this  fact  is  often  the  cause  of  serious  errors.  The 
dyspepsia  is  well  explained  by  a  reflex  action  dependent  upon  the 
sympathetic  nervous  system.  Dilatation  of  the  stomach  is  very 
frequent    in    metritis   of    long    duration.     Meteorism   caused   by 


106  Symptoms,  Progress  and  Diagnosis  of  the  Metrites. 

dyspepsia  is  a  great  obstructiou  to  palpation  of  the  abdomen  and  to 
bimanual  exploration. 

Uterine  cough. — In  diseases  of  the  uteras,  outside  of  any  affection 
of  the  respii-atory  organs,  and  ^\ithout  hysteria,  there  is  often 
observed  a  di-y  cough,  either  in  paroxysms  or  isolated,  but  very 
frequent.  It  is  generally  a  stuffy  cough,  exceptionallj'  it  has  a 
sonorous  and  metallic  character  which  makes  the  patient  anxious. 
It  is  characteristic  that  there  is  no  ausculatory  symptom  and  that 
the  cough  disappears  with  the  rehef  of  the  metritic  trouble. 

Reflexes  affecting  the  central  and  peripheral  nervous  system. — Nev- 
ralgias  and  neuroses  of  genital  organs. — The  cause  of  these  reflexes 
can  be  easily  explained  by  the  riclmess  of  the  genital  nerve  supply. 
Neuralgias  are  very  fi-equent.  Intercostal  neuralgia  is  so  frequent 
that  Bassereau  pretends  that  this  symptom  is  almost  always  hiiked 
to  a  metritis.  There  are  also  observed  facial  neuralgia,  sacral  neu- 
ralgia and,  very  frequently,  lumbo-abdominal,  with  radiation  of  the 
pain  into  the  femoro-cutaneous  branch,  especially  to  the  left  thigh. 
Peripheral  reflexes  may  affect  the  sensorial  nerves,  as  in  asthenopia. 
Finally,  I  only  mention  the  palpitation  of  the  heart,  which  may  be 
imputed  both  to  nervous  reflexes  and  to  the  anaemia.  The  distui'b- 
ances  of  the  general  nervous  system  are  of  extreme  variability.  In 
women  predisposed  to  hysteria  the  least  disturbance  in  the  internal 
genital  organs  may  call  out  the  manifestations  of  a  neurosis.  Thus 
is  at  once  explained  the  intensity  of  the  symptoms  that  can  be 
legitimately  attributed  to  such  an  insignificant  lesion  as  the  cica- 
tricial tissue  in  the  scar  of  a  lacerated  cervix,  and  the  marvelous 
success  of  certain  operations.  We  could  almost  say  that  there  is  a 
special  uterine  pathologj'  for  hysterical  women,  and  that  results  may 
be  hoped  for  in  measures  that  will  remam  withoiit  effect  in  women 
whose  nervous  system  is  less  vulnerable.  There  is  also  a  sequel  to 
genital  affections,  that  has  been  especially  observed  in  diseases  of 
the  uterus  (metritis,  displacements)  of  long  duration.  This  is  a 
state  of  asthenia,  an  excessive  depression  of  the  nervous  system, 
that  renders  a  woman  incapable  of  any  effort,  without,  however,  a 
corresponding  muscular  weakness,  or  an  impairment  of  the  general 
health. 

General  state. — The  pain,  which  prevents  exercise ;  the  dyspepsia, 
which  is  an  obstacle  to  alimentation ;  the  state  of  the  nervous  system, 
which  has  a  depressing  influence  upon  nutrition,  all  concur  in 
producing  a  rapid  alteration  of  the  general  health  giving  the  usual 
chloro- anaemic  aspect,  the  earthy  tint  of  the  face,  the  dark  cii'cles 
around  the  eyes  and  the  expression  of  suffering  to  the  face  which 
characterizes  what  we  call  the  uterine  facies. 

Such  is  the  assemblage  of  rational  signs  which  constitute  the  group 
common  to  all  diseases  of  the  internal  genital  organs,  but  which  is 
never  so  marked  as  in  metritis.     The  study  of  the  physical  signs 


Symptoms,  Progress  and  Diagnosis  of  the  Metrites.  107 

revealed  by  direct  examination  will  enable  ns  to  locate  the  disease 
in  the  uterus. 

Physical  signs. — On  digital  examination,  which  should  always  be 
associated  with  abdominal  palpation  —  bimanual  exploration  —  the 
cervix  is  found  enlarged  and  altered  in  consistency  (except  in  very 
rare  cases  where  only  the  body  of  the  uterus  is  the  seat  of  inflam- 
mation). It  is  larger,  more  open,  sometimes  unctuous  or  velvety  to 
the  touch  when  it  presents  an  ulcerated  surface.  In  certain  points 
can  be  felt  small,  hard,  shot-like  bodies,  which  are  glandular  cysts. 
The  finger  also  finds  the  lacerations,  on  which  I  have  dwelt  at 
length  in  connection  with  of  the  pathological  anatoniy. 

By  pressing  on  the  cervix,  either  at  the  edge  of  one  of  the  lips,  or 
at  the  torn  commissure,  a  very  sharp  pain  is  sometimes  produced, 
which  may  present  the  acute  character  of  neuralgia.  If  this  explo- 
ration is  not  painful,  ballottement  is  sometimes  so.  The  finger  also 
permits  recognition  of  the  mobility  of  the  uterus  and  of  the  fact  that 
the  culs-de-sac  are  fi-ee  in  cases  not  complicated  by  periuterine  in- 
flammation. 

The  first  examination  with  the  speculum  will  be  made,  by  prefer- 
ence, with  the  patient  in  the  dorsal  position,  by  the  use  of  a  bivalve 
speculum,  or  with  two  retractors.  It  shows  that  the  cervix  is  larger 
than  normal,  sometimes  filling  the  fundus  of  the  vagina  and  changed 
in  form ;  in  nuUiparous  women,  in  place  of  being  conical,  it  is  cyl- 
indrical, in  the  woman  who  has  borne  children  it  is  swollen  and  if 
there  are  lacerations,  it  assumes  various  forms.  The  color  varies 
from  a  bright  red  to  a  violet  red.  A  viscid  flow  of  mucus,  either 
purely  purulent  or  streaked  with  purulent  striae  and  sanguineous 
filaments,  escapes  from  the  os  uteri,  especially  if  care  is  taken  to 
press  softly  several  times  with  the  valves  of  the  speculum  in  such  a 
way  as  to  express  the  discharge.  The  mucosa  of  the  os  often  presents 
an  ulcerated  appearance.  These  apparent  losses  of  substance  will 
sometimes  be  very  small,  disseminated  (the  folliculities  of  some 
authors)  or  superficial,  resembling  a  slight  vesication  (erosion), 
sometimes  deep,  smooth  and  glazed,  sometimes  gi'anular  (ulceration) 
or  sometimes  yellowish,  granular  bodies  similar  to  the  small  pustules 
of  acne,  wiU  indicate  Nabothian  cysts.  Lacerations  of  the  cervix 
are  not  so  perceptible  to  the  eye  as  they  are  to  the  touch,  and  their 
ulcerated  surface  is  better  exposed  by  the  bivalve  speculum  than  by 
the  cylindrical.  To  separate  the  two  lips  a  divergent  volsella  may 
be  used,  or  simply  two  small  tenaculums.  Eectal  touch  is  a  useful 
supplement  to  vaginal  exploration.  Its  results  are  negative  in 
metritis. 

The  introduction  of  the  uterine  sound  will  develop  a  few  interest- 
ing characteristics.  The  uterine  cavity  is  usually  found  enlarged. 
It  is  necessary,  however,  to  guard  against  one  source  of  error. 
When  the  uterus  is  sHghtly  deviated  to  one  side  the  sound  does  not 


108  St/nqitonis,  Proc/ress  and  D'uuino^h  of  the  Metrites. 

really  meaaure  the  deptli  of  the  organ  hut  that  of  aii  oblique  line 
described  toward  the  angle  of  the  fundus  opposite  the  side  to  whic-h 
it  is  deviated.  To  obviate  this  error  the  uterus  is  brought  into 
position  by  bimanual  manipulation,  or  by  placing  the  woman  in  the 
genu-pectoral  position.  The  sound  often  causes  pain,  but  it  is  to 
far  tosay  that  the  exact  points  most  affected  by  the  endo-metiitis 
can  thus  be  located.  In  reality  it  is  more  often  the  movement 
imparted  to  the  whole  of  the  organ,  rather  than  any  pressure 
on  the  mucosa,  that  causes  the  pain  A  flow  of  blood,  when  the 
sound  has  penetrated  without  effort,  is  a  sure  indication  of  the 
alteration  of  the  mucous  membrane.  If  there  are  marked  fuugosi- 
ties  they  may  even  be  felt  sometimes  with  the  sound. 

Different  forms  of  metritis. — Acute  form. — In  the  beginning 
of  a  metritis,  for  example,  that  from  a  dilatation  or  a  probing  done 
without  antiseptic  precautions,  etc.,  there  maybe  observed  rigors  and 
fever.  Acute  phenomena  also  occur  in  the  course  of  a  chronic  metritis, 
in  consequence  of  fatigue,  or  simply  at  the  time  of  menstruation. 
However,  when  metritis  assumes  this  form  at  its  onset,  or  by  acute 
exacerbations  of  the  chronic  disease,  direct  exploration  permits 
recognition  of  the  sensitiveness  of  the  organ  and  the  heat  of  the 
vagina,  and  also  reveals  tln-obbing,  redness  and  swelling  of  the 
mucosa  of  the  cervix,  in  a  word,  all  the  classic  symptoms  of  acute 
inflammation.  The  symptoms  usually  diminish  in  intensity  some- 
what rapidly  but  are  subject  to  reappearance  in  a  new  exacerbation. 

Catarrhal  form.— This  is  characterized  by  the  predommance  of 
two  symptoms,  the  lesions  of  the  ceiTix  and  the  intensity  of  the 
leucorrhcea.  This  form  is  especially  observed  among  young  women 
and  is  frequentlj'  accompanied  liy  the  phenomena  of  nervous  reflexes 
that  have  been  mentioned.  The  principal  location  of  the  disease  is 
in  the  cervix,  it  is  the  cervical  catarrh  of  certain  authors.  I  be- 
lieve, however,  that  it  is  a  mistake  to  describe  it  as  a  circumscribed 
lesion.  In  these  cases  there  is  always,  a  concomitant  alteration  of 
the  mucosa  of  the  body  of  the  uterus  which  should  not  be  neglected 
therapeutically. 

Hamorvhaific  form . — Here,  on  the  contrary,  it  is  the  body  of  the 
organ  that  is  diseased  and  the  cervix  may  present  a  relatively 
healthy  appearance.  This  form  is  observed  among  young  girls  at  the 
time  of  estabUshment  of  the  menstruation,  and  among  women  at  the 
menopause.  Finally  this  is  the  form  particularly  assumed  by  post- 
abortiim  metrites ;  when  simple,  almost  invisible  particles  of  the 
decidua  are  grafted  upon  the  uterine  mucosa.  It  milst  be 
remembered  that  early  abortions  are  fi-equently  um-ecognized,  and 
that  this  pathological  condition  intervenes  more  fi-equently  than  is 
supposed. 

It  is  in  the  inveterate  cataiThal  and  luemorrhagic  forms  that  the 
profound  alterations  of  the  mucous  membrane  of  the  body  of  the 


Symptoms,  Progress  and  Diagnosis  of  the  Metrites.  1U9 

uterus  become  vegitating,  fungous,  polypoid.  This  exuberant  pro- 
liferation of  the  interstitial  and  glandular  elements  may  also  affect 
the  cervical  mucosa.  The  diseased  condition  then  becomes  apparent 
and  constitutes  a  new  symptom,  but  does  not  make  it  neccessary  to 
change  the  name  of  the  affection.  Mucous  polypi  and  follicul^ir 
hypertrophies  of  the  cervix  are  lesions  of  metritis  and  should  be 
described  with  them,  both  anatomically  and  clinically.  The  appear- 
ance of  these  polypi  recalls  the  soft  polypi  of  the  nasal  fossae  ;  they 
are  reddish  or  purplish,  of  the  volume  of  a  pear  or  a  nut,  sometimes 
with  a  thin  pedicle,  sometimes  sessile.  Follicular  hypertrophy  of 
the  cervix  is  formed  by  vegetation  of  glandular  tissue  in  the 
thiclmess  of  one  of  the  lips,  wMch  thus  undergoes  an  hypertrophic 
elongation  of  soft  consistency,  grooved  or  anfractuous.  Its  size  may 
be  such  as  to  present  at  the  vulva.  The  polypi  often  produce  grave 
intei'mittent  hfemorrhages.  Hypertrophic  elongatioii  especially 
accompanies  the  catarrhal  form.  The  hfemorrhagic  form  may  cause 
continual  losses,  with  short  respites,  during  some  weeks,  so  that 
some  patients  are  brought  to  a  state  of  extreme  anaemia.  The  flow 
occurs  most  frequently  without  colic,  the  patients  complain  only  of 
more  or  less  intense  lumbar  pains  and  present  various  neuralgic 
points. 

Chronic  paivful  form. — I  have  characterized  this  form  by  the  term 
painful  because  the  painful  state  of  the  organ  is  the  prominent 
symptom.  It  is  absolutely  false  to  represent  chronic  metritis  as 
the  consequence  and  as  the  remains  of  an  acute  metritis.  It  is 
much  more  exact  to  say  that  it  is  the  result  of  an  infection  of  slow 
evolution,  which  sometimes  is  quiescent,  before  making  its  appear- 
ance, long  enough  to  allow  the  infecting  caiise  to  disappear.  There 
are  here,  in  a  word,  some  facts  analogous  to  those  which  Yerneuil 
has  grouped  under  the  term  latent  microhism.  This  form  has  an 
insiduous  course,  misleading  intermissions  and  unnoticed  exacer- 
bations. It  is  most  frequently  due  to  a  locahzed  puerperal  infection 
of  very  late  date.  Delay  of  normal  involution,  engorgement  char- 
acterized by  abnormal  size  of  the  organ,  sense  of  weight,  pain  in  the 
loins  making  walking  and  standing  painful  and  dysmenorrhcea,  such 
are  its  first  symptoms.  It  may  even  pass  unnoticed  during  the  first 
months  ;  the  woman  who  only  feels  ill  in  consequence  of  some  fatigue 
attributes  to  this  occasional  cause  the  origin  of  her  affection.  Later, 
the  pains  become  more  severe  and  may  condemn  the  patient  to 
complete  repose.  Local  examinations  give  very  different  results 
according  as  they  are  made  during  acute  exacerbations  or  between 
these  periods.  In  the  first  case  we  have  the  symptoms  noted  before 
as  occurring  during  the  acute  form.  In  the  second  case,  between  the 
periods  of  acute  exacerbations,  the  cervix  is  found  a  little  swoUen, 
hard,  as  if  sclerosed,  often  iiTegular  from  the  presence  of  old  lacer- 
ations, of  a  consistency  almost  wooden  in  parts,  in  other  pai-ts 


110  Symptoms,  Progress  and  Diagnosis  of  the  Metrites. 

covered  with  small  uodules.  The  speculum  shows  this  tumefaction 
and  a  variable  congestion;  often  there  is  a  very  characteristic 
appearance  as  if  the  cei-vix  were  covered  with  pimples.  If  there  are 
lacerations  of  the  cer\ix  ectropion  may  be  observed,  but  without  the 
fungous  appearance  of  the  catan-hal  form ;  it  is  smoother,  like  a  cica- 
trizing ulcer.  There  is  frequently  a  concomitant  uterine  deviation. 
Probing  the  uterus  gives  only  a  shghtly  marked  increase  in  the  length 
of  the  cavity. 

There  is  a  variety  of  chi-onic,  painful  metritis  which  merits  special 
description,  that  is  membranous  or  erfoliaceous  dysmemorrhuia.  The 
capital  symptom  is  the  painful  eUmination  at  the  menstnial  period 
of  a  part  or  the  whole  of  the  uterine  mucosa  which  presents  the  histo- 
logical alterations  of  acute  inflammation  (interstitial  endometritis). 
(Fig.  45).  The  patient  may  suffer  but  little  in  the  intervals  between 
menstruation,  although  they  present,  however,  symptoms  of 
metritis,  among  others  that  of  leucorrhoea.  Many  authors  have  not 
recognized  this  relation,  but  have  made  membranous  dysmenorrhcea 
an  affection  wholly  distinct  fi-om  the  metrites.  Others  have  clearly 
seen  the  relationship.  If  the  origin  of  the  affection  is  sought,  it  is 
almost  always  found  that  it  relates  to  a  previous  accouchement  or 
miscaniage,  more  rarely  to  the  estabhshment  of  menstmation  (the 
importance  of  these  phases  of  genital  Hfe  in  the  development  of  the 
metrites  is  well  known).  We  can  say  then  that  membranous  dys- 
menorrhcea is  a  true  chi'onic  metritis,  ^vith  escerbations  of  the  form 
of  acute  metritis  and  inflammatory  desquamation  at  the  moment  of 
the  menstnial  period.  This  is  why  it  enters  into  the  category  of 
the  chi'onic  forms,  in  a  clinical  point  of  view,  and  into  the  class  of  the 
acute  forms,  in  an  anatomical.  Sometimes  only  fi-agments  are 
exfoliated,  sometimes  the  membranous  sac  is  complete  and  the  form 
of  the  uteiine  ca%"ity  can  be  recognized — an  internal  smooth  face 
riddled  with  small  openings,  and  an  external  surface,  irregular  and 
ragged.  This  wiU  not  be  mistaken  for  the  membrane  produced  by 
a  miscarriage  if  examined  attentively  (after  a  short  immersion  in 
picric  acid)  and  the  absence  of  the  ^•iUi  of  the  chorion  noted.  On 
the  contrary  the  presence  or  absence  of  the  cells  of  the  decidua  is 
not  pathognomonic,  as  has  been  beheved.  This  special  manifestation 
of  certain  chi-onic  metrites  usuaUy  lasts  until  the  menopause,  unless 
energetic  treatment  is  instituted.  It  may  be  accompanied  bj' 
menon"hagia.  Although  it  ustiaUy  causes  sterihty,  pregnancy  has 
been  noted  during  tliis  disease,  with  return  after  delivery. 

Clinical  coiirse. — Prognosis. — All  forms  of  metritis  are  obstinate. 
As  soon  as  the  mucosa  has  been  diseased  for  a  certain  length  of 
time,  the  muscular  coat,  the  parenchyma,  becomes  altered  in  turn. 
If  the  structiu'al  lesions  of  the  mucosa  subside,  the  sclerosis  of  the 
utenis  and  the  small  cysts  of  the  cei-vix  still  remain  none  the  less 
distinct.     Now  these  remaining  lesions  are  sufficient  to  cause  the 


Symptoms,  Progress  and  Diagnosis  of  the.  Metrites.  Ill 

morbid  state  which  constitutes  chi-onic  metritis,  and  this  is  why 
every  metritis,  which  is  not  promptly  relieved,  is  liable  to  become 
incurable.  Does  metritis  predispose  to  cancer  ?  It  has  been  con- 
tended that  an  inflammation  of  the  uterine  mucosa  of  long  standing, 
when  it  takes  a  glandular  form,  may  easily  terminate  in  adenoma ; 
that  the  typical  adenoma  may  become  atypical,  and  that,  by  a  pro- 
gressive transition,  a  malignant  neoplasm  a  true  cancer  of  the  body 
may  result. 

Diagnosis. — Error  may  arise  from  magnifying  the  importance  of 
symptoms,  the  concomitant  signs  being  few.  The  increase  in  the 
size  of  the  uterus  together  with  dyspeptic  symptoms  may  lead  to 
the  diagnosis  of  pregnancy,  especially  if  a  temporary  amenorrhoea 
adds  to  the  doubt.     Time  will  dispel  the  doubt. 

An  abundant  leucorrhoea  associated  with  ulceration  of  the  cervix 
gives  rise  to  suspicion  of  cancer.  The  character  of  the  discharge, 
however,  is  different  in  the  two  diseases.  In  cancer  the  leucorrhoea 
is  not  muco-purulent  and  viscid,  it  is  serous,  reddish  and  of  a 
special  fetid  odor.  The  ulceration  is  full  of  cavities,  is  marked  by 
yellowish  points,  and  has  hard  borders  when  it  is  not  surrounded 
by  a  cauliflower  vegetation.  It  destroys  the  tissues  that  support  it, 
giving  rise  to  loss  of  substance  not  found  in  the  pseudo  ulceration 
of  metritis.  The  hard  and  irregular  sweUiug  of  the  cervix  produced 
by  the  development  of  cysts  and  the  concomitant  sclerosis,  give,  it 
is  true,  a  sensation  to  the  touch  analogous  to  that  of  cancerous 
nodules.  Punctures  of  the  cervix,  by  evacuating  the  cysts  and 
relieving  the  congestion  will  facihtate  the  diagnosis.  If  necessary 
a  smaU  piece  may  be  excised  and  examined  histologically.  From 
the  sharp  and  regular  pains,  the  tenacious  discharge  of  fetid  muco- 
pus  mixed  with  blood,  the  considerable  increase  in  the  size  of  the 
uterus  and  the  examination  of  fragments  removed  by  the  curette, 
we  will  be  able  to  make  a  diagnosis  of  cancer  of  the  body  of  the  uterus. 

A  hsemorrhagic  metritis  must  not  be  confounded  with  the  metror- 
rhagia induced  by  an  early  miscarriage.  The  history  and  the 
examination  of  the  clots  expelled  are  important. 

Fibrinous  polypi,  that  are  only  the  debris  of  the  placenta,  or  of  the 
viUi  of  the  chorion,  remaining  grafted  in  the  uterus  and  preserving 
some  degree  of  vitality  for  several  weeks  and  even  months  after 
an  accouchement  or  an  abortion,  are  distinguished  by  the  anamnesis 
and  the  histological  examination  of  a  small  section  removed  by  the 
blunt  curette. 

Fibroid  tumors  and  intrauterine  fibrous  polypi  give  rise  also  to 
a  group  of  symptoms  analogous  to  that  of  metritis  and  to  copious 
haemorrhages.  The  examination  of  the  uterus  by  bimanual  explo- 
ration, by  the  sound,  and,  if  need  be,  by  dilatation  of  the  cervix  serves 
as  a  guarantee  against  error. 

Salpingitis,  as  I  have  said,  often  co-exists  with  metritis.     The 


112  Symptoms,  Pnxjress  and  Tfmiinims  of  the  Metrites. 

examinatiou  must  determine  which  oue  of  these  two  lesions  pre- 
dominates. By  bimanual  exploration,  T\'ith  the  aid  of  anaesthesia, 
the  condition  of  the  appeiadages  will  lie  carefully  examined.  If  they 
are  not  enlarged,  hut  only  sUghtly  tender  to  palpation,  while  the 
uterus  presents  the  objective  signs  described,  the  diagnosis  of 
metritis  is  made. 

I  have  already  mentioned  the  existence  of  metrites  symptomatic 
of  primary  and  non-inflammatory  diseases  of  the  appendages.  It 
is  difficult  to  determine  hi  what  way  the  uterus  becomes  diseased 
in  these  eases.  A  small  ovarian  tumor  has  been  observed  to  be  the 
principal  point  of  dei)arture,  apparently,  of  profuse  haemorrhages 
associated  with  an  hyperplastic  endometritis.  Brenuecke  and 
Loehlein,  who  have  reported  observations  of  this  kind,  believe  that 
the  reflex  hyperemia  provoked  by  the  ovarian  irritation  is  sufficient 
to  cause  the  hyperplasia  of  the  uterine  mucosa.  It  is  better  to  say 
that  this  state  of  permanent  congestion  creates  a  true  morbid  recep- 
ti\dty  by  reason  of  wliich  the  numerous  causes  of  congestion — genns 
inhabiting  the  vagina,  and  germs  fi-om  ^^-ithout — are  able  to  exercise 
their  noxious  influence,  and,  by  overcoming  the  enfeebled  organic 
resistance,  to  provoke  an  inflammation. 

However  this  may  be,  two  facts  appear  to  be  established  which 
should  not  be  forgotten  by  the  physician:  1.  There  exists  an  inti- 
mate relation  between  inflammation  of  the  utems  and  that  of  the 
appendages  (ovaries  and  tubes),  and  the  last  should  always  be 
sought,  because,  whether  idiopathic  or  deuteropathic,  it  is  the  most 
important  in  its  bearing  upon  the  question  of  operative  interference. 
2.  Alterations  of  the  ovaries,  whatever  their  natiu-e,  may  fi-om  the 
first  simulate  metritis  by  their  indirect  effect  iipou  the  uterus.  The 
uterine  lesion,  at  first  simply  congestive,  tends  to  develop  into  a 
true  inflammation. 

Cystitis  may  be  associated  with  an  mflammation  of  the  utetus, 
or  give  rise  by  itself  to  painful  sjanptoms  which  simulate  a  metritis. 
The  same  is  true  of  proctitis,  with  tenesmus,  and  even  glaiiy 
secretion  (anal  leucorrhoea),  which  sometimes  appears  wth  a 
metritis.  It  is  necessary,  then,  to  always  guard  against  taking  an 
effect  for  a  cause.  I  have  observed  a  case  of  pain  in  the  sphincter 
ani  which  disappeared  after  the  cure  of  a  catarrhal  metritis.  It  is 
exceptional,  on  the  other  hand,  that  a  disease  of  the  rectum  causes 
the  symptoms  of  a  pseudo  metritis.  I  have  reported  a  case  of 
polypus  of  the  rectum  which  gave  rise  to  distui'bances  that  were 
attril)uted  to  metritis.  Removal  of  the  polypus  caused  the  dis- 
appearance of  the  iiterine  symptoms. 

Distm-bances  of  the  general  health  or  reflex  troubles  are  often  so 
marked  that  they  mask  the  local  lesion.  A  woman  complains  of 
constant  cough,  of  difficult  breathing,  of  progi-essive  loss  of  flesh, 
and  (inly  a  little  of  leucorrhcea  and  abdominal  pains.     Tuberculosis 


Treatment  of  the  Metrites.  113 

might  be  suspected  until  auscultation  of  the  chest  and  local  exami- 
nation dissipate  this  error.  Again,  it  is  the  stomach  that  seems 
affected  by  the  prominence  of  the  symptoms.  Want  of  appetite, 
vomiting,  flatulence,  associated  with  the  physical  signs,  would  lead 
to  the  diagnosis  of  dila'tation  of  the  stomach.  This  may  really  exii^it, 
hut  is  symptomatic  of  a  metritis,  which  should  demand  the  first 
attention.  Finally,  a  gi-eat  number  of  young  women  believe  they 
have  clilorosis  or  heart  disease  because  they  suffer  precordial 
anxiety,  palpitations,  and  because  auscultation  reveals  cardiac  and 
vascular  souffles.  But  if  the  uterus  is  examined  it  will  be  quickly 
recognized  that  these  symptoms  are  due  to  a  metritis.  The  same 
is  true  of  various  neuralgias  and  of  the  different  nervous  states  which 
simulate  hysteria.  In  any  woman  affected  ^\\i\\  a  chronic  disease 
examination  of  the  uterus  should  not  be  neglected. 


CHAPTER  VII. 


TREATMENT    OF    THE    METRITES. 

The  prophylaxis  of  uterine  inflammations  was  greatly  advanced 
by  the  introduction  of  antisepsis  after  accouchement,  for  it  is  to 
puerperal  infection,  more  or  less  attenuated  and  localized,  that  the 
majority  of  metrites  are  due.  The  perfect  cleansing  of  tlie  uterine 
cavity  of  the  deliris  of  membranes  and  placenta  are  of  the  greatest 
importance.  The  question  whether  expectation  is  better  than  active 
interference,  in  my  opinion,  has  been  wrongly  discussed.  Budin  is 
too  much  opposed  to  what  he  calls  the  exaggerated  fear  of  accidents 
in  consequence  of  abstention.  This  he  bases  on  statistics  drawn 
from  cases  treated  at  the  Charity  hospital  during  a  period  of  three 
years,  comprising  forty-six  retentions  out  of  two  hundred  and  ten 
cases  of  miscarriage.  He  has  only  seen  septicfemia  four  times,  out 
of  this  number,  and  only  one  death  (septic  pneumonia :').  Budin  con- 
trols hfemorrhage  by  the  tampon,  septic  accidents  by  intrauterine 
and  vaginal  injections  of  subhmate  solution  (1-2000  to  1-3000)  or  of 
carbolic  (20-1000  to  30-1000)  associated  with  the  administration  of 
quinine  internally.  It  is  certainly  not  to  be  doubted  that  immediate 
accidents  can  be  thus  avoided,  but  can  the  same  be  said  of  ulterior 
troubles,  of  metritis  and  of  salpingitis.  Are  these  patients  truly 
eihred,  by  having  escaped  death  ?  Certainly  not.  I  cannot  condemn 
such  timid  therapeutics  too  much.  However  little  there  is  reason  to 
suspect  the  retention  of  fcetal  appendages  in  the  uterine  cavity,  it  is 


114  Treatment  of  tlie  Metrites. 

necessary  to  hasten  to  make  exploration,  cleansing  and  disinfeetiou, 
without  waiting  for  the  appearance  of  hnemon-hages,  for  when  they 
do  appear  the  mucosa  is  already  infected.  Even  the  finger  itself 
can  be  used  during  a  delay,  soon  after  labor  or  miscarriage.  After 
a  careful  curetting  (completed  by  an  hemostatic  injection  of  per- 
chloride  and  by  antiseptic  irrigation),  the  temperature  falls  from 
two  to  three  degrees,  if  fever  is  ah-eady  estabhshed ;  its  reappearance 
is  prevented  and  rapid  return  to  the  normal  is  assui-ed,  in  cases 
where  decomposition  of  the  debris  has  not  ah-eady  commenced.  The 
intrauterine  ecoui-Ulon,  or  swab,  which  has  been  advised,  is  a  verj' 
inefficient  instrument. 

Before  taldng  up  the  therapeutic  indications  applying  to  the 
diverse  forms  of  this  affection,  I  ■will  discuss  first  the  common  treat- 
ment which  apphes  equally  to  all : 

Immobilization  of  the  abdomen  is  recommended  with  an  abdominal 
belt  of  di-illing  ^vith  a  large  flannel  bandage,  passed  twice  around  the 
lower  abdomen,  and  iucliuing  a  Httle  fi-om  above  downward.  This 
immobilization  is  a  gi-eat  comfort  to  patients  in  walking.  All  fatigue, 
\ioleut  efforts,  and  sexual  relations  are  proscribed.  Constipation  is 
eombatted,  preferably  by  a  choice  of  ahments  (gi-een  vegetables,  rye 
bread,  prunes)  and  nuld  purgatives,  and  emollient  injections  to 
which  are  added  some  spoonfuls  of  glycerme.  Some  patients  find 
it  well  to  take  at  each  meal  a  tablespoonful  of  linseed  meal  or  of 
white  mustard  in  a  glass  of  water.  These  small  foreign  bodies 
mechanically  excite  hpyersecretion  and  contractions  of  the  intes- 
tines. The  use  of  drastic  purgatives  (aloes,  podophyllum)  long 
continued  has  disadvantages,  but  should  be  employed  as  required. 
It  is  very  important  to  excite  regular  evacuations  of  the  bowels  to 
diminish  pelvic  congestion.  Attempt  is  made  to  restore  general 
nutrition,  so  often  altered,  by  tonics  of  the  kind  suitable  to  the 
patient :  in  the  lymphatic  temperament,  cod-liver  oil,  phosphate  of 
lime ;  in  the  arthi-itic,  arsenical  preparations,  and  to  all,  ii-on  asso- 
ciated A\ith  quinine  and  rheubarb  vnll  he  administered  with  success. 
Finally,  hydrotherapy  is  a  powerful  auxiliary  that  should  not  be 
neglected,  especially  if  the  metritis  has  produced  antemia  and  has 
caused  nervous  sjTnptoms.  There  is  no  disease  in  which  thermal 
waters  have  been  more  advised.  It  is  certain  that  they  have  a  very 
salutary  effect  on  the  general  health  especially,  and  indirectly  on  the 
local  condition.  The  principal  indication  should  be  draMii  from  the 
general  condition  of  the  patient  and  from  the  reflex  tlisturbances. 
For  very  anaemic  patients  ^vill  be  prescribed  by  preference  the 
femrginous,  sulphurous  and  arsenical  waters  and  sea  baths ;  to 
dyspeptics,  alkaline  or  slightly  purgative  waters ;  to  neuropathic 
patients,  indifferent  waters,  choosing  an  agreeable  site  and  a  some- 
what elevated  altitude.  Finally  the  sodium  chloride  waters  have  an 
incontestable  action,  not  only  on   the  lymphatic   and   scrofulous 


Treatment  of  the-  Metrites.  115 

constitution  but  also  on  viceral  congestions  and  are  of  actual  benefit 
in  the  beginning  of  some  forms  of  chronic  metritis,  when  engorgement 
of  the  body  predominates  without  great  alterations  of  the  cervix. 

Special  treatment. — In  acute  metritis  repose  in  bed  is  absolutely 
necessary.  Sitz  baths  are  prescribed,  with  the  appKcation  in  the 
bath  of  a  small  speculum  to  admit  the  liquid  to  the  cervix.  Mild, 
repeated  purgatives  are  also  given.  If  the  pain  is  very  severe,  it  is 
soothed  by  douches  containing  laudanum  or  suppositories  containing 
opiates.  The  daily  application  of  glycerine  tampons,  left  in  place 
twelve  hours,  is  an  excellent  antiphlogistic.  The  affinity  of  the 
glycerine  for  water  causes  a  considerable  serous  flow.  Prolonged 
vaginal  mjections  or  hot  douches  (45°  F.  to  50°  F.)  are  of  great 
service.  This  therapeutic  means  is  susceptible  of  numerous  appli- 
cations and  it  is  useful  to  give  some  exact  indications  for  its 
employment.  The  injection  should  be  given  with  the  woman  at  the 
edge  of  the  bed,  the  legs  supported  on  each  side,  and  the  pelvis 
slightly  elevated.  An  impervious  sheet  should  be  placed  under  the 
buttocks  and  folded  below  into  the  form  of  a  trough  which  empties 
into  a  receptacle.  The  douche-can,  which  should  hold  at  least  three 
litres,  is  filled  with  water  at  45°  (there  is  a  loss  of  about  two  degrees 
in  passing  through  the  apparatus)  and  elevated  about  three  feet 
above  the  patient.  If  the  vestibule  of  the  vagina,  the  vulva  and  the 
perinseum  are  smeared  with  vaseline,  before  commencing  the 
injection,  the  action  of  the  hot  water  will  be  less  disagreeable.  At 
least  three  htres  are  used,  and  ten  or  more  successively.  The 
injection  is  repeated  twice  a  day.  On  finishing,  two  fingers  depress 
the  fourchette  to  afford  outlet  to  the  accumulated  liquid.  It  is  useful 
to  introduce  a  glycerine  tampon  immediately  after.  The  patient 
should  remain  in  a  recumbent  posture  an  hour  after  this  irrigation. 

If  the  acute  state  is  prolonged  recourse  is  had  to  local  blood- 
letting. For  this  we  have  a  special  instrument,  the  uterine  scarifi- 
cator, but  the  ordinary  bistoury,  rolled  in  an  adhesive  plaster  so  as 
to  leave  only  one  centimetre  of  the  blade  free,  is  efficient.  After 
having  irrigated  the  vagina,  the  speculum  is  introduced  and  the 
cervix  is  punctured  with  the  bistoury  in  a  dozen  points,  not  too 
distant  from  the  os  uteri.  As  much  to  make  this  operation 
antiseptic  as  to  favor  the  flow  of  blood,  continued  irrigation  with  a 
warm  carbolized  solution,  1-100,  is  useful.  When  the  flow  of  blood 
is  judged  sufficient,  the  speculum  is  withdrawn,  the  vagina  emptied, 
and  a  tampon  of  iodoform  gauze  introduced  against  the  cervix 
controls  the  haemorrhage.  This  procedure  is  preferable  to  the 
employment  of  leeches.  It  is  not  painful  and  calls  for  no  angesthetic. 
In  order  that  this  local  bleeding  may  be  efficacious,  it  should  be 
renewed  several  times  (every  two  days). 

Membranous  dysmenorrhoea.— Any  treatment  but  curet- 
ting generally  fails.     On  the  contrary  this  procedure  gives  excellent 


116  Treatment  of  the  Metrites. 

results.  It  should  be  followed  by  injeetious  of  tincture  of  iodine 
and  made  according  to  rules  that  will  be  given  later.  If  there  is 
also  stenosis  of  the  cer\-ix,  dilatation  with  the  laminaria  tents  or 
\s-ith  EUinger's  dilator,  is  uidicated.  Landowski  has  pubhshed  some 
successes  obtained  by  the  galvano-caustie.  I  believe  this  procedure 
is  good  but  curetting  is  more  certain  and  more  expeditious. 

Acute  blennorrliagic  metritis  should  be  energetically  treated 
by  vaginal  and  intrauterine  iujec-tions,  both  antiseptic  and  slightly 
caustic.  Guerin  has  shown  the  good  effects  of  the  intrauteiiue 
injection  of  a  weak  solution  of  silver  nitrate  (five  eentigi-amnies  to 
thirty  gi-ammes  of  Avater).  Fritsch  has  recently  recommended 
cldoride  of  zinc,  1-100,  for  vaginal  injections,  and  more  concentrated 
for  intrauterine  cauterization.  Vaginitis  and  endometritis  should 
be  similarly  treated  in  parallel  cases.  It  should  not  be  forgotten, 
however,  that  blenuorrhagia  may  have  long  disappeared  fi-om  the 
vagina  and  stiU  remain  in  the  utenis  and  in  the  urethra.  It  is  in 
the  latter  that  the  last  traces,  which  characterize  the  nature  of  the 
uteiiae  affection,  should  be  sought.  Against  the  vaginitis  and  the 
urethritis  subhmate  injections,  1-2000,  associated  with  the  use  of 
iodoform  suppositories,  have  given  me  exceUent  results.  In  acute 
blemioiThagic  metritis  I  use  curetting,  followed  by  intrauterine 
cauterization  with  concentrated  zinc  chloride,  appHed  on  a  bit  of 
cotton  twisted  on  the  sound 

Catarrlial  metritis. — The  general  treatment  indicated  should  be 
especially  followed  as  this  form  quickly  induces  chloro-anaemia. 
This  form  of  metritis  also  demands  the  most  scrupulous  cleanliness 
and  antisepsis  of  the  vagina.  For  this  treatment  acts  indirectly,  it 
is  triie,  but  not  the  less  efficaciously  on  the  cerA"ix,  which  is  usually 
the  region  most  affected.  Patients  wiU  be  adnsed  to  remain  in  a 
recumbent  posture  after  the  morning  injection,  as  they  keep  a 
certain  amount  of  the  hquid  in  the  upper  part  of  the  canal.  Subh- 
mate solution,  1-3000,  is  the  best  injection,  but  its  use  should  not 
be  too  much  prolonged.  Another  exceUent  injection  may  be  made 
by  adding  to  a  htre  of  water  a  tablespoonful  of  boracic  acid,  a  tea- 
spoonful  of  tannic  acid,  or  a  half-teaspoonful  of  powdered  alum. 
But  to  completely  cure  an  inflammation  of  the  mucosa  of  the  body 
of  the  utenis  intrauterine  treatment  will  be  necessary.  This  we  may 
divide  into  thi-ee  principal  procediu-es :  antiseptic  cleansiug,  cauteri- 
zation, currettmg.  These  may  be  employed  singly  in  combination. 
To  this  hitrauterine  treatment  it  is  frequently  necessary  to  add 
surgical  treatment  for  the  lesions  of  the  cerrix,  the  ulcerations  and 
lacerations  which  are  of  such  gi-eat  importance  in  this  catarrhal  form 
of  metritis. 

Antiseptic  cleansing. — (a).  Intrauterine  irrigation. — The  anti- 
septic irrigations  of  large  quantity,  but  of  feeble  strength,  of  which 
we  speak  here,  must  not  be  confused  with  the  injections  of  a  small 


Treatment  of  the  Metrites.  117 

quantity  of  a  substance  which  powerfully  modifies  the  uterine 
miicosa,  to  greater  or  less  extent.  The  latter  belong  to  the  second 
class.  Schultze,  especially,  has  advised  the  first  procedure.  He 
dilates  with  laminaria  and  introduces  an  intrauterine  recurrent 
sound  and  irrigates  the  cavity  with  carboHzed  water  (2-100).  This 
treatment  is  not  sufiieient  in  the  inveterate  cases.  It  appears  apph-,. 
cable  only  to  mild  cases  of  endometritis,  without  deep  imphcation  of 
the  mucous  membrane.  An  irrigation  is  made  every  day  of  a  half 
litre.  If  necessary  the  cervix  is  dilated  with  a  dilator,  or  by  lami- 
naria tents.  When  rehef  is  still  delayed,  after  the  use  of  tins  simple 
means,  we  proceed  at  once  to  cauterization  and  curetting. 

(b).  Drainage. — Fehling  has  constructed  glass  drainage-tubes, 
pierced  with  smaU  holes ;  Ahfield,  hoUow  rubber  cylinders,  and 
Schwartz,  meshes  of  glass  threads,  acting  by  capillary  attraction. 
It  does  not  appear,  however,  that  these  procedures  have  given  good 
results.  It  is  probable  by  the  presence  of  the  foreign  body  in  the 
uterus,  that  they  are  adapted  to  cause,  rather  than  to  cure,  metritis. 
Tliis  is  not  the  case  with  drainage  by  the  capillary  action  of  iodo- 
form gauze,  which  can  not  be  separated  fi'om  tamponnement. 

(c).  Tamponnement. — In  1882  Fritsch  employed  a  procedure 
especially  appHed  to  bleunorrhagic  metritis.  A  strip  of  gauze  seventy- 
five  centimetres  long  and  two  to  thi-ee  centimetres  wide  is  pushed 
into  the  uterus  and  packed  into  the  cavity.  This  strip  is  then 
removed  and  the  manoeuvi-e  repeated  in  such  a  way  as  to  carefully 
cleanse  the  uterine  ca^dty.  Then  a  final  strip  of  iodoform  gauze  is 
introduced  and  left  from  twenty-four  to  forty-eight  hours  (or 
removed  earher  if  it  provokes  coHc).  I  beheve  that  this  means  is 
much  less  simple  than  curetting  followed  by  cauterization,  and  in 
]ny  practice  it  is  reserved  for  cases  where  energetic  disinfection  is 
necessary  (cancer  of  the  body  of  the  uterus,  sloughing  fibroid) ;  it  is 
also  used  as  a  simple  haemostatic  after  enucleations  and  the  detach- 
ment of  fibroids  in  pieces. 


Fig,  58. — Doleris'  ecouvillon. 

(d).  Ecouvillonage. — Many  gynaecologists  are  contented,  after 
dilating  the  cervix  if  neccessary,  with  cleansing  the  uterine  cavity  by 
the  aid  of  a  sound  on  the  end  of  wliich  is  twisted  a  small  quantity  of 
absorbent  cotton.  This  is  a  very  simple  means.  The  cotton  tampon 
on  the  end  of  the  sound  can  be  easily  adjusted  as  to  the  amount  of 
the  dilatation  of  the  cervix.  The  cotton  is  tvnsted  on  the  end  of  the 
sound,  dipped  in  a  solution  of  sublimate,  1-1000,  or  of  carbohc,  20- 
1000,  then  squeezed  out  gently  before  introducing  it  into  the  uterine 
cavity.  After  introduction  it  is  turned  about  in  such  a  way  as  to  clean 
the  uterine  walls.     This  cleansing  can  be  made  the  first  step  of  a 


118  Treatment  nf  the  Metrites. 

cauterization  by  means  of  a  new  tampon.  Doleris  prefers,  instead 
of  this  simple  procedure,  the  use  of  the  ecouvillon,  or  swab  (Fig.  58), 
an  instrument  similar  to  those  used  for  cleaning  bottles.  The  in- 
stniment  is  immersed  in  a  solution  of  subUmate,  1-1000,  and 
introduced  into  the  iiterine  cavity  by  a  spkal  movement  and  turned 
m  the  opi^nsite  direction  on  being  withdra^vn.  The  swab  can  also  be 
charged  ■with  medicated  solutions,  the  same  as  the  cotton  tampon. 
Doleris  beheves  that  in  using  the  ecouvillon,  it  produces  a  cleansing 
and  scraping  \\-ith  destruction  of  the  mucosa.  Those  who  know  the 
force  that  must  be  used  to  remove  the  mucous  membrane  with  a 
blunt  instrument  will  see  that  this  last  point  is  a  delusion.  I  believe 
it  is  impossible  to  destroy  by  simple  rubbing  with  a  brush  all  the 
elements  of  this  diseased  membrane.  The  ecou\-illon,  hke  the  cotton 
tampon,  can  only  aspke  to  the  role  of  a  cleansing  agent  or  of  an 
intrauterine  medicator.  There  are  some  eases,  especially  among 
nulHparous  women,  in  which,  though  the  cervical  canity  is  dilated 
and  full  of  mucus,  the  external  orifice  is  very  small  and  opposes  the 
exit  of  the  secretion.  It  is  better,  then,  in  place  of  dilatation,  to 
incise  the  external  os.  The  incision  should  be  made  crucial,  with 
scissors  curved  on  the  flat,  or  a  blunt  bistomy.  After  this  it  will 
be  easy  to  explore  the  cer\'ical  cavity.  The  small  incisions  cicatrize 
spontaneously. 

Intrauterine  cauterization. — The  du-ect  and  momentary 
appHcation  of  the  caustic,  by  means  of  a  caustic  holder,  is  preferable 
to  the  use  of  crayons  blindly  left  in  the  uterine  cavity  for  a  certain 
time  and  then  withdrawn.  The  use  of  the  latter  method  may  produce 
a  destruction  of  tissue  leading  to  obliteration  of  the  orifices  of  the 
tubes  and  to  strictures  of  the  cervical  canal.  The  galvano-caustic  of 
Apostoli  is  less  convenient  and  less  sure  than  the  curette  and  to  me 
it  appears  liable  to  the  danger  of  causing  sterility  and  cicatrices  in 
the  uterine  cavity.  Toucliing  with  caustic  liquids  can  easily  be  done 
by  the  use  of  the  absorbent-cotton  tampon  twisted  on  the  cotton 
carrier.  Professor  Pajot  uses,  according  to  the  case,  nitrate  of  silver 
in  various  preparations,  acid  nitrate  of  mercury,  anhydrous  nitric 
acid,  chloride  of  zinc,  percliloride  of  iron,  and  the  thermo-  and  actual 
cautery.  Numerous  other  caustics  are  used  by  various  authors,  but 
I  do  not  employ  this  method  of  treatment.  In  spite  of  all  precautions 
it  is  difficult  to  avoid  narrowing  the  cervical  opening.  But  this  is 
not  the  principal  olijection,  unless  a  dilatation  is  made  before  each 
application,  or  a  tamponade  in  the  mterval  between,  we  cannot  be 
certain  of  penetrating  much  beyond  the  cervix.  Only  a  partial 
application  is  made,  and  while  the  cerrical  portion  is  too  strongly 
cauterized,  the  therapeutic  action  in  the  body  of  the  uterus  is  nil. 

Cauterization  by  caustic  injections  have  been  the  subject  of  long 
discussion,  as  to  the  danger  of  the  liquid  passing  into  the  fallopian 
tubes.     This  passage,  wliieh  is  easily  accomphshed  on  the  cadaver. 


Treatment  of  the  Metrites.  119 

owing  to  conditions  that  do  not  exist  in  the  hving,  is  in  reaUty  very 
difficult,  provided  two  conditions  are  ohserved :  The  canula,  by 
which  the  injection  is  made,  should  leave  space  between  it  and  the 
walls  of  the  cervical  canal  sufficient  to  allow  easy  exit  to  the  return- 
ing liquid.  The  injection  should  not  be  made  with  force,  and  the 
jet  of  hquid  should  not  be  thrown  in  the  axis  of  the  uterine  canal. 
Several  kinds  of  caustic  liquids  are  used,  the  best  appears  to  be  the 
tincture  of  iodine,  ereasoted  glycerine,  and  the  perchloride  of  iron. 
Aljout  three  grammes  are  injected  with  the  intrauterine  syringe.  I 
frequently  employ  injections  of  the  perchloride  of  iron,  but  only 
some  days  after  a  preliminary  curetting,  itself  followed  by  an 
injection  of  perchloride  of  iron.  I  begin  the  iodine  injection  five 
days  after  the  operation  and,  in  cases  of  very  intense  catarrh,  give 
an  injection  every  two  days  for  two  weeks.  I  prefer  the  tincture  of 
iodine  to  the  solutions  of  creasote  in  glycerine,  one-third  to  one-tenth, 
employed  by  Doleris.  The  canula  of  the  syringe  is  introduced  into 
the  uterine  cavity,  by  the  aid  of  the  eye,  at  the  bottom  of  a  specu- 
lum. .  The  direction  of  the  cavity  is  first  ascertained  with  the  sound. 
If  there  are  difficulties  the  cervix  is  fixed  with  the  tenaculum  and  a 
shght  traction  made  in  direction  opposite  to  the  deviation  of  the  body 
of  the  uterus.  The  injection  is  forced  in  slowly,  the  canula  being  with- 
drawn a  little  from  the  fundus  of  the  organ.  Ordinarily  it  is  not 
necessary  to  dilate  the  cervix,  this  is  only  done  if  there  is  not  free 
exit  for  the  hquid  by  the  side  of  the  canula  of  the  syringe.  During 
the  intrauterine  injection  free  irrigation  of  the  vagina  must  be 
made  to  prevent  cauterization  of  its  walls.  I  have  seen  quite  severe 
pain,  vomiting  and  syncope  follow  an  intrauterine  injection,  but  I 
have  never  observed  any  serious  accident.  The  tincture  of  iodine 
has  been  accused  of  precipitating  the  albumen  and  of  forming  clots 
in  the  uterine  cavity.  This  error  has  been  refuted  by  Nott.  The 
iodine  simply  forms  a  very  fine  precipitate  and  its  antiseptic  action 
is  thus  prolonged.  The  essential  oils  and  the  aromatic  compositions, 
such  as  creasote,  have  a  more  fugitive  action.  With  regard  to 
iodoform,  it  is  dangerous  to  inject  it  into  the  uterus  in  solution,  on 
account  of  toxic  absorption. 

Curetting'. — Curettement  of  the  uterus  has  lately  come  into  new 
favor  under  the  ase  of  antiseptics.  It  now  occupies  a  considerable 
place  in  the  treatment  of  metritis.  The  choice  of  a  curette  is  of 
importance.  There  are  several  varieties  the  principal  ones  being : 
Simons'  sharp  curette  (which  should  be  reserved  for  cancer  of  the 
cervix  and  for  largely-developed  uterine  fungosities),  Sims'  sharp 
curette  (excellent  for  the  detachment  of  polypoid  products),  the 
flexible,  blunt  curette  of  Thomas,  modified  by  Simpson,  and  the 
Eecamier-Eoux  eurrette  which  Martin  has  adopted  and  which  I 
prefer  (Fig.  59).  I  am  a  resolute  partisan  of  the  blunt  curette  in 
endometritis,  as  here  it  is  only  necessary  to  forcibly  scrape  a  hard 


120  Treatment  of  the  Metrites. 

muscular  wall,  lined  with  a  covering  that  is  naturally  soft  and 
becomes  still  more  softened  by  inflammation.  Thus  it  is  sufficient 
to  scrape  the  interior  of  the  uterus  viith  a  thin  blade  to  he  sure  of 
detacliiug  aU  that  has  little  resistance,  that  is,  precisely,  the  chseased 
mucosa.  Blunt  curettes  have  also  the  advantage  of  not  exj)osing 
the  uterine  parenchyma  to  wounds,  while  they  act  ii\ith  a  sufficiently 
great  force.  If  this  force  is  always  used  obliquely  the  danger 
of  perforation  (outside  the  post-partum  period)  is  reduced  to  a 
mimimum. 


Fic.  59. — Recamier-Roux  curette. 

The  whole  thiclmess  of  the  mucosa  is  never  removed  by  curetting. 
The  glands  peneti'ate  into  the  muscular  layer,  and  these  tenninal 
culs-de-sae  and  a  smaU  portion  of  mucous  chorion  remain  attached  to 
the  parenchjTna  in  spite  of  the  most  energetic  scraping.  They  then 
serve  for  a  rapid  reconstruction  of  this  membrane.  For  this  reason 
curetting  for  metritis  becomes  a  modifn'ing  agent,  in  distinction  fi-om 
destructive  cui'et  ting  for  neoplastic  gro\\i:hs,  and  aside  hiovaevplorative 
curetting  designed  to  remove  a  fi-agment  for  cUagnostic  pm-pose.  In 
the  last  two  procedures  the  shaii)  curette  is  preferable.  The  uterine 
mucosa  can  not  be  compared  to  other  mucous  membranes ;  it  has  a 
special  power  of  regeneration.  The  changes  in  menstruation  and 
pregnancy  show  that  a  gi-eat  thickness,  even  almost  its  total  thick- 
ness, may  be  exfoliated  and  then  rapidly  restored.  Cnretting  pro- 
vokes, artificially,  a  therapeutic  end,  an  exfoliation  of  the  mucosa 
comparable  to  that  of  the  decidua.  It  substitutes  a  new  mucosa, 
regenerated  in  an  antiseptic  medium,  for  a  membrane  infected  by 
germs  and  that  has  iindergone  profound  alterations,  the  repair  of 
which  would  be  very  long  and  difficult.  After  curettmg,  the  fecundity 
of  the  woman  is  no  more  compromised  than  after  deKvery  or  mis- 
caniage.  It  should  be  remarked  that  after  the  operation  the  first 
menstruation  is  often  absent,  it  may  even  be  delayed  until  the  fourth 
mouth. 

Technique  of  curetting. — The  operation  is  made  preferal)ly  during 
the  first  few  days  wliich  foUow  menstruation.  Although  there  is  so 
httle  pain  that  it  is  sometimes  done  \nthout  anaesthesia,  I  generally 
use  it.  The  prehminary  antisepsis  of  the  vagina  and  vulva  is  made 
according  to  the  established  rules.  The  patient  is  placed  in  the 
dorsal  position,  two  assistants  supporting  the  hmbs.  The  one  to 
the  left  of  the  operator  holds  the  short  speculum  which  depresses 
the  fourchette:  the  one  to  the  right  holds  the  fixation  forceps  and 
the  tube  tor  continuous  irrigation.     The  knees  of  the  ptitient  bemg 


Treatment  of  the  Metrites.  121 

supported  under  the  arms  of  the  assistant,  one  hand  of  each  remains 
free  to  hold  the  vaginal  retractors.  The  cervix  is  drawn  toward  the 
vulva  by  a  vulsellum  fixed  in  the  anterior  lip.  The  direction  and 
the  depth  of  the  uterus  are  ascertained  with  the  sound.  The 
currette  is  then  presented  at  the  cervical  opening.  Nine  times  out 
of  ten  the  currette  passes  without  resistance.  If  there  is  resistance 
it  is  overcome  by  EUinger's  dilator  or  by  the  passage  of  two  or  three 
of  Hegar's  bougies.  The  currette  is  then  directed  toward  the  fundus 
and  the  scraping  is  made  by  carrying  it  successively  over  the 
anterior  and  posterior  surfaces  aiid  the  fundus  to  the  angles  and 
lateral  borders.  A  certain  force  is  necessary,  to  such  an  extent  as 
to  make  the  uterine  tissue  squeak  under  the  effoi-t.  The  instrument 
is  then  withdrawn  and  quickly  plunged,  to  cleanse  it,  into  a  glass  of 
strongly  carbolized  water  held  to  the  right  of  the  operator.  A  second 
time  the  curette  is  passed  to  the  same  extent,  and  a  second  curetting 
performed  by  following  the  uterine  surface  as  before.  The  operator 
will  proceed  rapidly,  a  complete  scraping  scarcely  demanding  three 
minutes.  Immediately  after,  a  recurrent  sound  is  introduced  and 
the  canula  for  continuous  irrigation  (which  has  been  used  on  the 
cervix  during  the  curetting .  adjusted  to  it.  The  uterine  cavity  is 
then  weU  washed  out  with  the  hot  carbolic  solution,  1-100,  which 
has  served  for  irrigation.  A  quarter  to  half  a  litre  is  used  until  the 
Avater  returns  scarcely  tinged  with  blood.  This  irrigation  is  haemo- 
static and  antiseptic  and  serves  to  remove  the  clots  and  pieces  of 
membrane  from  the  uterine  cavity. 

The  sound  is  withdrawn  and  replaced  by  the  intrauterine  syringe 
(filled  with  a  solution  of  perchloride  of  iron,  or  with  the  tincture  of 
iodine),  wliichis  pushed  to  the  fundus.  In  injecting,  the  syringe  is 
withdrawn  by  degrees,  so  as  to  place  the  last  of  the  injection  in  the 
cervix.  During  this  time  the  liquid  from  the  irrigator,  which  is 
continually  playing  on  the  cervix,  serves  to  dilute  the  caustic  liquid 
as  it  escapes  from  the  uterine  cavity  and  to  prevent  it  from  nritating 
the  vulva  and  vagina.  The  recurrent  catheter  is  again  introduced 
and  a  new  douching  of  the  cavity  is  quickly  made.  This  removes 
from  the  ceiwix  the  excess  of  caustic  and  the  last  clots.  If  there  is 
diificulty  in  introducing  the  catheter,  by  reason  of  the  contraction  of 
the  cervix  from  the  action  of  the  caustic,  smaU  intermittent  jets  can 
be  thrown  into  the  uterine  cavity  without  danger,  by  the  aid  of  the 
long,  fine  canula  which  serves  for  the  continued  irrigation.  It  is 
only  necessary  to  take  care  not  to  distend  the  uterus,  and  not  to 
pass  the  canula  too  far  into  .  the  cervix.  This  terminates  the 
operation,  the  vulseUum  is  removed,  the  uterus  replaced,  and  a 
tampon  of  iodoform  gauze  is  placed  in  the  fundus  of  the  vagina,  to 
be  left  until  the  third  day.  Every  morning  and  evening  after,  a 
profuse  vaginal  irrigation  is  made  with  sublimate  solution,  1-2000, 
and,  if  the  x^atarrhal  metritis  was  of  long  standing,  if  the  mucosa 


122  Treatment  of  the  Metrites. 

removed  presented  many  vegetations,  if  there  are  symptomss  of  a 
slight  concomitant  salpingitis,  an  intrauterine  injection  of  tincture 
of  iodine  should  be  given  every  second  day.  From  four  to  eight 
injections  will  constitute  a  complete  treatment.  The  tincture  of 
iodine  I  use  for  the  first  caustic  injection,  which  immediately 
follows  the  curetting,  where  there  is  a  recent  catarrhal  metritis.  In 
invererate  cases,  or  when  considerable  oozing  of  blood  calls  for  it,  I 
use  the  percliloride  of  iron. 

As  a  general  rule,  in  women  who  have  borne  children,  the  pre- 
liminary stage  of  dilatation,  recommended  by  many  authors,  may 
be  dispensed  with.  It  is  useless,  as  regards  the  introduction  of  the 
instrument ;  it  is  illusory,  as  regards  the  ease  of  the  escape  of  tlie 
secretions,  for  the  artificial  dilatation  only  persists  for  a  few  hours. 
As  to  the  debris  of  the  mucosa  and  the  clots  they  should  be  carefully 
expelled  by  intrauterine  doucliing.  The  omission  of  tliis  step  is  of 
importance.  Slow  dilatation  of  the  cervix  is.  often  painful.  The 
woman  who  undergoes  it  the  night  before  operation,  generally  has  a 
night  of  uisomnia  and  the  next  day  is  in  a  state  of  great  nervous 
irritation  and  sometimes  has  a  little  fever  from  an  exacerbation  of 
her  disease  excited  by  the  dilatation. 

The  perforation  of  the  uterus  so  much  dreaded  by  some  is  not  to 
be  feared  m  endometritis,  if  only  the  blunt  curette  is  used  and 
always  obhquely  in  relation  to  the  uterine  tissue.  It  is  necessary, 
however,  to  be  mindfiil  of  the  consistency  of  the  uterus  after  paiiu- 
rition  or  recent  miscarriage.  It  is  then  very  soft  and  tliin  and  may 
be  perforated  Avith  unexpected  facility.  Tliis  danger  A\'iU  generally 
be  avoided  by  the  liistory  and  by  the  enlargement  of  the  uterme 
cavity  and  the  softness  of  the  cernx.  Haemorrhage  has  also  been 
cited  among  the  possible  accidents  from  curetting  the  uterus.  I 
have  not  observed  it  once  out  of  hundreds  of  operations.  The 
astringent  injection  which  terminates  the  operation  leaves  only  an 
insignificant  oozmg.  I  will  not  dwell  on  peritonitis,  even  subacute 
and  locahzed,  as  I  have  not  seen  a  single  case. 

Curetting  the  uterus  is  the  true  rational  treatment  for  catarrhal 
metritis.  As  soon  as  simple  means  fail  (general  treatment,  vaginal 
and  intrauterine  injections  and  local  treatment)  eurettmg  should  at 
once  be  resorted  to.  To  Mait  too  long,  will  be  to  give  the  lesions  of 
the  mucosa  time  to  accentuate  themselves;  will  be  to  expose  the 
parenchyma  of  the  body  and  cervix  to  sclerotic  alterations  and  to 
follicular  degeneration,  and  will  be  to  allow  time  for  the  possible 
propagation  in  the  fallopian  tubes,  so  frequent  in  inveterate  ca- 
tarrhal metritis. 

Mvcom  polypi  of  the  cennx  are  removed  by  seizing  with  the  forceps 
and  giving  them  sufficient  torsion  to  break  then-  pedicle.  If  they 
are  numerous  and  sessile  they  are  scraped  off  with  Sims'  sliai-p 
curette  and  the  bleeding  surface  touched  with  the  thernio-cautery 


Treatment  of  the  Metrites.  123 

or  with  perehloride  of  iron.  Finally  if  the  cervix  is  much  altered, 
especially  if  it  presents  follicular  hypertrophy,  recourse  to  Schroeder's 
operation  is  necessary  (excission  of  the  mucosa  as  described  later). 

Ulcerations  of  the  cervix,  which  are  ordinarily,  as  has  been  shown  in 
their  pathology,  only  glandular  neoplasms,  more  or  less  hyper- 
trophied,  scarcely  exist  independently  of  a  more  profound  inflam- 
mation of  the  body  of  the  uterus.  From  this  it  follows,  that  to  cure 
the  ulceration  in  its  first  stage,  it  is  generally  sufficient  to  cure  the 
inflammation.  But  this  is  only  true  in  cases  taken  early.  Later, 
the  glandular  proliferation  is  an  acquired  legion  which  necessitates 
topical  treatment,  or  even  removal  with  the  knife.  As  the  first  treat- 
ment, then,  of  ulcerations  of  the  cervix,  that  of  the  concomitant 
endometritis  is  necessary ;  in  the  second  place,  topical  applications 
of  nitrate  of  silver  or  tincture  of  iodine  every  two  days.  Nitric, 
acetic,  carbolic  and  chromic  acids  are  also  employed,  but  all  these 
caustics  tend  to  strictures  of  the  cervix  and  I  am  very  suspicious 
of  them.  When  these  procedures  fail,  or  when  the  patient  demands 
instant  relief,  even  at  the  price  of  an  operation,  the  surgical  treat- 
ment will  be  of  great  service.  Schroeder's  operation,  or  excision  of 
the  diseased  mucosa,  should  then  be  made,  following  the  explanation 
made  later.  This  operation  gives  excellent  results  by  substituting  a 
healthy  surface  for  a  diseased  one,  permitting  at  the  same  time 
removal  of  the  sclerosed  portions  of  the  cervix  and  of  those  that  have 
undergone  cystic  degeneration.  It  does  not  create  a  cicatrix  and 
consequently  should  not  be  an  obstacle  to  delivery,  as  has  been 
stated  by  numerous  observers.  I  have  always  associated  it  with 
curetting  of  the  cervix.  It  appears  especially  indicated :  in  cases  of 
ulceration  of  long  duration,  with  hypertrophy  of  the  cervix;  in 
ulceration,  with  narrowing  of  the  cervical  cavity ;  in  ulceration,  with 
deep  laceration  of  the  cervix.  It  is  much  superior  to  Emmet's 
operation,  fulfilling  all  its  indications,  as  well  as  others  that  this 
procedure  does  not  cover. 

Ulcerations  complicated  tvith  lacerations.  —  We  know  the  capital 
role  that  Emmet  makes  these  factors  play  in  uterine  pathology. 
His  views  have  had,  at  least,  the  good  effect  of  showing  that  these 
lesions  cannot  always  be  neglected.  Is  it  the  previous  inflammation 
of  the  cervix  which  impedes  cicatrization  of  the  laceration,  as 
Schoeder  believes,  or,  the  laceration  which  causes  the  catarrh  and 
the  ulcerations,  as  Emmet  maintains?  I  think  that  these  two 
opinions  can  be  reconciled  and  form  by.  their  union  one  of  those 
vicious  circles  so  frequent  in  pathology.  However  that  may  be,  it 
is  evident  that  the  freshening  of  the  cervix  and  suture,  or  Emmet's 
operation,  can  be  undertaken  on  an  ulcerated  cervix  only  after  cure 
of  the  ulceration.  In  fact,  Emmet  prescribes  a  preparatory  treat- 
ment which  often  lasts  some  months.  There  is  no  parallel,  then, 
between  Schi-oeder's  operation  and  that  advised  by  Emmet.     The 


124  Treatment  of  the  Metrites. 

first  is  especially  addressed  to  cerncal  eatan-h,  the  second  to  the 
cicatricial  tissue  dependent  upon  laceration.  The  catarrh  or  the 
ulceration  are,  for  Emmet,  only  accessory  phenomena,  the  princi- 
pal pathological  element  being  the  sclerosed  tissue  wliich  compresses 
the  vessels,  glands  and  nerves.  It  is  not  then  apropos  of  the  treat- 
ment of  ulcerated  laceration  dependent  upon  catarrhal  metritis,  but 
under  the  head  of  the  cicatrized  lacerations  observed  in  chronic 
meti'itis  that  I  shall  describe  trachelorrhaphy.  Schroeder's  operation, 
although  directly  indicated,  as  has  been  said,  in  the  cer^ical 
laceration  coexisting  with  a  large  ulceration,  will  also  be  described 
by  the  side  of  Emmet's  operation,  since  it  too  is  called  for  in  the 
treatment  of  painful  clnonic  metritis.  When  the  ulcerated  lacer- 
ation is  of  small  extent  cicatrization  can  sometimes  be  caused  by 
simple  cauterizations  with  the  thermo-cautery.  But  this  means 
should  not  be  used  in  large  ulcerated  surfaces  and  in  deep  tears. 
The  cicatricial  tissue  that  they  produce  becomes  in  itself  then  a 
pathological  condition. 

Hsemorrliagic  metritis.  —  The  treatment  divides  itself  into 
two  portions :  that  for  the  hsemorrhage,  which  is  a  palliative  and 
may  be  required  at  once ;  and  that  for  the  affection  itself,  wliich 
should  be  curative. 

Treatment  of  the  hcemoirhage. — The  patient  ^\ill  be  kept  in  a  hori- 
zontal position.  Prolonged  vaginal  injections  of  very  hot  water  may 
he  employed.  Ergot  is  rarely  useful.  Digitalis  has  been  praisrd 
as  acting  both  on  the  hemorrhage  and  the  inflammatory  stati-. 
Hydrastis,  in  the  fluid  extract,  twenty  drops,  thi-ee  times  a  day,  has 
been  used  with  excellent  results.  The  use  of  a  laminaria  tent  will 
sometimes  cause  cessation  of  the  hasmorrhage  for  several  days, 
without  doubt  from  the  contraction  of  the  uterus  or  from  a  vaso- 
motor reflex  action.  A  short  respite  is  thus  obtained.  The  same 
is  true  of  intrauterine  injections  of  perchloride  of  iron,  which 
give  rise  to  a  temporary  amelioration,  although  cures  have  been 
published  after  their  use.  In  case  of  serious  htemorrhage  it  may 
be  necessary  to  tampon  the  vagina.  This  should  be  done  with  the 
tampons  impregnated  with  alum,  or  with  strips  of  gauze  as  already 
indicated.  Ordinary  iodoform  gauze  should  not  be  used.  Lister's 
carbolized  gauze  is  preferable  and  maj'  be  powdered  with  iodoform. 

I  will  note  a  palliative  measure  which  has  given  Fritsch  good 
results,  that  is,  the  ligature  of  the  uterine  arteries.  This  can  be 
practiced  without  incision,  as  already  described,  or  by  incismg  the 
culs-de-sac  on  each  side  of  the  cervix  to  an  extent  of  tlu-ee  centi- 
meters. The  two  vaginal  rami  are  first  met  and  tied,  then  the 
tnink  of  the  uterine  artery  itself  receives  the  ligature. 

The  best  hiemostatit-  in  biemorrhagic  metritis,  and  at  the  same 
time  the  best  cm-ative  treatment,  is  curetting.  This  will  be  practiced 
as  soon  as  possible,  according  to  the  rules  indicated,  and  followed 


Treatment  of  the  Metrites.  125 

by  an  injection  of  perchloride  of  iron.  One  can  operate  in  the  face 
of  haemorrhage.  I  have  very  often  seen  it  arrested  instantaneously 
after  the  curetting,  and  attribute  this  not  only  to  the  destruction 
of  the  bleeding  surface,  but  also  to  the  contraction  of  the  muscular 
walls  and  bloodvessels  caused  by  the  scraping.  A  single  intra- 
uterine injection  is  generally  sufficient.  Cure  is  thus  rapidly 
obtained.  There  are  some  rare  cases,  qualified  by  the  name 
hemorrhagic  metritis,  in  which  all  these  means  fail  and  the  metror- 
rhagia persists  until  it  threatens  the  woman's  life.  In  these  cases 
castration  and  even  vaginal  hysterectomy  have  been  turned  to  as  a 
last  resort. 

Painful  chronic  metritis. — Local  bleedings  by  scarification 
of  the  cervix  have  a  frequent  application  in  this  form.  Here,  not 
only  the  immediate  antiplilogistic  effect  is  sought,  but  also  the 
evacuation  of  the  small  superficial  cysts,  which,  after  having  been 
one  of  the  effects  of  the  inflammation,  in  their  turn  cause  a  hyper- 
semic  condition.  With  regard  to  cauterization  with  the  thermo- 
cautery, and  in  particular  igni  puncture,  I  believe  they  are  inferior 
to  punctures  and  scarifications  with  the  knife.  The  cicatrices, 
which  succeed  to  the  employment  of  cauterization,  add  to  the 
sclerosis  of  the  cervix  and  favor  cystic  degeneration,  stenosis  of 
the  cervical  canal,  and  the  compression  of  nervous  filaments  with 
their  consequent  morbid  reflexes.  Better  than  these  are  anti- 
plilogistic dressings,  discutient  and  antiseptic,  consisting  in  an 
application  to  the  cervix  of  the  tincture  of  iodine,  followed  by  a 
glycerine  tampon  lightly  powdered  with  iodoform.  Aside  from  the 
exaggerated  estimate  of  the  beneficial  action  of  tampons,  it  is 
necessary  to  attribute  to  it  a  certain  mechanical  role.  I  often  use 
it  by  placing  with  care  a  series  of  small  masses  of  cotton  soaked 
in  glycerine  around  the  cervix  in  the  culs-de-sac,  packing  them  in 
lightly.  These  tampons  may  be  left  in  place  four  to  five  days  if 
care  is  taken  to  add  a  little  iodoform  to  the  glycerine. 

Hot  injections  will  often  be  of  great  help,  especially  in  two  con- 
ditions, one,  in  the  case  where  the  chronic  metritis  is  complicated 
by  perimetritic  inflammation,  more  or  less  marked,  the  other,  when 
very  sensitive  patients  complain  of  sharp  pains,  as  in  the  cases 
which  Lisfranc  called  hysteralgia  and  which  Eouth  qualified  by  the 
^expressive  term,  irritable  uterus.  Great  amelioration  of  these 
pains  has  also  been  obtained  by  the  use  of  electricity,  introducing 
into  the  uterus  the  bipolar  excitor. 

Massage  has  been  advised  in  chronic  metritis  as  well  as  in  pro- 
lapsus, displacements,  chronic  perimetritic  inflammations,  etc.  It 
is  necessary  to  distinguish  general  massage,  a  species  of  passive 
gymnastics  which  favors  nutrition,  and  local  massage,  ha^dng  for 
its  object  the  relief  of  congestion  and  the  diminution  of  volume  by 
manipulation  of  the  diseased  organ.     The  last  is  practiced  by  two 


126  Treatment  of  the  Metrites. 

or  three  fingers  introduced  into  the  vagina  or  rectum,  sustaining 
the  posterior  face  of  the  uterus,  while  the  other  hand  placed  above 
the  pubes  exerts  gentle  and  progressive  manipulations  amounting 
to  a  sort  of  kneading. 

There  remain  a  great  number  of  painful  chronic  metrites  in 
which  all  these  procedures  are  without  effect.  The  cervix  remains 
large,  swollen,  hard  and  mammillated,  in  spite  of  scarifications, 
topical  applications  and  thermal  treatment.  The  corpus  uteri  is 
augmented  in  volume,  heavy  and  painful  to  ballottement.  The 
patients  are  so  infirm  that  the  least  exertion  prostrates,  all  exercise 
is  painful.  It  is  in  these  cases  that  surgery  renders  very  great 
service  by  an  operation  which  acts  on  the  cervix  and  reacts  on  the 
body  of  the  uterus,  that  is,  amputation  of  the  cervical  mucosa.  In 
consequence  of  amputations  of  the  cervix  there  results  a  great 
diminution  in  the  volume  of  the  body.  Whether  this  regression  is 
due  to  fatty  metamorphosis  of  the  hypertrophied  connective  tissue, 
or  due  to  a  true  reflex  vaso-motor  or  trophic  action,  is  not  clearly 
made  out.  But  whatever  the  explanation  may  be,  the  fact  of  its 
occurrence  is  i;ndeniable. 

Amputation  is  indicated  as  an  ultimate  operation  in  the  case  of 
chronic  metritis  with  increase  in  volume  of  the  corpus  uteri.  Besides 
this,  in  cases  of  marked  sclerosis  of  the  cervix,  it  gives  to  the 
external  orifice  a  calibre  and  a  suppleness  which  causes  a  cessation 
of  the  dysmenorrhoea,  due  sometimes  to  the  ridgidity  and  irregu- 
larity of  this  segment.  A  formal  centra-indication  will  be  found 
in  an  acute  perimetritic  inflammation ;  but  I  do  not  consider  as  an 
absolute  contra-indication,  the  existence  of  an  old,  extinct  peri- 
metritis, which  has  left  plastic  deposits  and  adhesions  around  the 
uterus.  It  is  essential,  however,  to  know  that  an  old  focus  of 
inflammation  may  be  rekindled  in  consequence  of  any  operation, 
even  perfectly  aseptic,  practiced  on  the  uterus.  If  not  always 
abstaining  from  surgical  interference  in  such  cases  one  should  at 
least  be  on  guard,  and  assured,  before  attacking  the  cer'S'ix,  that  it 
is  not  rather  in  the  appendages  or  in  adhesions  that  the  causes  of 
the  symptoms  should  be  soiight. 

The  technique  of  the  operation  of  amputation  of  the  cer^dx  has 
been  very  much  perfected  and  at  the  same  time  simplified  by  the 
employment  of  cutting  instruments.  The  fear  of  haemorrhage  was 
legitimate  at  a  time  when  the  operation  was  laboriously  performed. 
Thus  the  cervix  was  amputated  only  with  means  of  exercising 
haemostasis,  extemporaneous  ligature,  linear  ecraseur,  galvano-  or 
thermo-cautery.  The  preliminary  compression  of  the  cervix  with 
a  rubber  ring  attests  the  same  excesssive  care.  In  operating 
rapidly  the  loss  of  blood  is  insignificant  and  the  sutures  arrest  it 
quickly  and  completely  ;  it  is  only  essential  to  make  the  knots  with 
care,  and  to  tie  three  superposed  knots  if  catgut  be  used. 


Treatment  of  the  Metrites. 


127 


I  will  not  tarry  to  describe  those  processes  of  which  I  disapprove. 
Every  section  with  the  ecraseur  or  by  incandescent  instruments 
has  the  great  disadvantage  of  leaving  a  cicatrix,  a  concentric 
retraction,  ending  in  stenosis.  Circular  amputations  without  flaps 
are  dangerous  in  a  hcemorrhagic  point  of  view.  For  the  cervix 
uteri  the  only  procedures  to  be  recommended  are  those  which' 
permit,  by  exact  coaptation  and  perfect  union,  the  reconstruction 
of  an  OS  uteri  not  susceptible  of  contraction.  Two  procedures  of 
this  kind  may  be  employed  according  to  the  special  indications : 
1.  Amputation  with  two  flaps  (for  each  lip) ;  2.  Amputation  with 
one  flap  (which  can  be  graduated  at  will  in  such  a  jvay  as  to  make 
as  needed  only  a  simple  excision  of  the  internal  mucosa). 


Fig.  6o. — Amputation  of  the  cervix  with  two  flaps  (Simon). 
A.  Seen  in  section.     B.  Sutures  in  place. 

1.  Amputation  with  two  flaps  (conical  excision  or  with  conical 
flaps)  should  be  preferred  when  the  internal  mucosa  of  the  cervix 
is  not  diseased  and  does  not  require  excision.  The  technique  may 
be  briefly  described :  Anaesthesia.  Patient  in  lithotomy  position ; 
vagina  irrigated ;  fourchette  depressed  by  a  short  speculum.  Con- 
tinued irrigation,  made  by  a  small  jet  from  a  long  canula  in  charge 
of  an  assistant,  who  also  holds  the  fixation  forceps.  Incision  of  the 
commissures  of  the  cervix,  as  far  as  the  cul-de-sac,  with  a  large 
convex  bistoury  or  with  strongly-curved  scissors.     Incision  of  the 


128  Treatment  of  tlie  Metrites. 

anterior  lip  from  the  internal  mucous  membrane  toward  the  bottom 
and  from  below  upward.  Second  incision  from  the  external 
mucosa  passing  to  rejoin  the  other  and  in  such  a  way  as  to  cut  off 
a  conical  segment  of  the  anterior  lip,  with  its  base  below,  its  summit 
above.  Suture  of  the  two  flaps  thus  obtained  with  a  strong  needle 
threaded  with  catgut,  taking  care  to  pass  the  needle  under  all  the 
raw  surface ;  five  or  six  stitches  are  necessary.  Same  procedure 
for  the  inferior  lip,  after  having  withdrawn  the  holding  forceps, 
using  the  threads  of  the  sutures  in  the  anterior  lip  to  keep  the 
cervix  depressed.  Suture  of  each  commissure  by  one  or  two 
stitches.  Section  of  the  ends  of  the  suture  thi-eads,  vaginal  irri- 
gation, replacement  of  the  uterus  and  iodoform  tampon  (Fig.  60). 
At  the  end  of  thi-ee  days  the  tampon  is  withdrawn  and  morning  and 
evening  antiseptic  irrigations  (sublimate  1-2000)  given.  It  is 
necessary  to  keep  the  patient  in  bed  for  at  least  fifteen  days ;  the 
cure  is  then  complete  without  the  removal  of  the  catgut  sutures,  as 
they  disappear  spontaneously. 

2.  Amputation  with  one  flaj:),  or  excision  of  the  mucous  membrane 
(Schi-oeder's  operation),  is  especially  applied  to  the  treatment  of  a 
special  form  of  metritis,  the  catarrhal  form,  with  rebellious  ulcer- 
ation and  more  or  less  profound  foUicular  degeneration  of  the 
cervix. 

However,  it  may  require  application  in  chi-ouic  metritis,  when  it 
appears  the  most  convenient,  by  reason  of  the  configuration  or  the 
consistency  of  the  cervix.  I  describe  it  here  so  as  not  to  separate 
the  description  of  operative  procedures.  Its  execution  is  a  little 
more  difficult  than  that  of  the  preceding  operation.  The  cervix  is 
made  accessible  in  the  same  mamier  and  the  bilateral  incision  is 
the  same.  From  this  moment  the  technique  is  as  follows :  Trans- 
verse incision  of  the  internal  mucous  membrane  of  the  anterior  lip 
and  semicircular  incision  of  the  external  mucosa,  surrounding  a 
lamella  of  the  tissue  of  the  cer%-ix  which  is  dissected  obliquely  to 
the  edge  of  the  internal  transverse  incision,  where  the  lamella  is 
completely  detached.  To  this  excised  portion  is  given  a  thickness 
varying  according  to  the  hypertrophy  or  to  the  alteration  of  the 
tissues.  Inversion  (entropion)  of  the  external  flap  thus  obtained ; 
suture  of  this  flap  to  the  internal  mucosa  with  five  or  six  catgut 
stitches;  the  curved  needle  should  pass  under  all  of  the  raw 
surface  ;  two  or  three  supplementary  stitches  are  ordinarily  neces- 
sary. Same  dissection  and  same  suture  for  the  posterior  hp  and 
sutiire  of  the  commissures,  etc.,  as  before  (Fig.  61).  Sometimes 
there  is  an  advantage  in  applying  the  two-flap  operation  to  one  lip 
and  Schi-oeder's  method  to  the  other.  It  is  generally  useful  to  pre- 
cede or  to  follow  this  operation  by  a  curetting  of  the  body  of  the 
uterus,  as  the  mucosa  is  always  more  or  less  altered.  I  use  the 
curette  last  so  as  not  to  be  hindered  by  the  oozing,  and  not  to 


Treatriunt  of  the  Metrites. 


129 


operate  on  a  cervix  that  has  been  shriveled  by  an  injection  of  the 
perchloride. 

Trachelorrhaphy,  or  Emmet's  operation,  should  give  way  to 
Sclu'oeder's  operation  whenever  cervical  catarrh  coexists  with  a 
unilateral  or  bilateral  laceration.  It  should  be  reserved  exclusively 
for  chi-onic  metritis  without  ulceration  of  the  cervix.  In  such 
cases  one  can  hope,  by  removing  the  cicatrical  tissue  and  restoring 
to  the  cervix  its  natural  foi-m,  to  remove  the  cause  of  the  pain  and 
irritation.  Besides,  it  cannot  be  doubted  that  trauma  of  the  cervix 
generally  has  a  favorable  effect  on  the  body  of  the  uterus,  as  much 
in  the  case  of  simple  freshening  of  the  tissues,  as  in  the  case  of 
amputation. 


Fig.  6i. — Schroeder's  operation.     A,   Position  of  the  sutures  in  the  anterior  lip. 
B.  Section  of  the  incision.     C.  Disposition  of  the  flap. 

The  patient  anaesthetized,  the  assistants  are  disposed  as  for 
amputation  of  the  cervix.  The  uterrrs  is  drawn  down  with  the 
volsella  (or  by  two  threads  passed  through  one  of  the  lips).  One 
pair  of  forceps  seizes  the  cervix  at  the  border  of  the  anterior  lip, 
near  the  laceration,  the  other  pair  grasps  the  posterior  lip  at  a 
corresponding  point.  One  dissects  then  in  a  single  piece  all  of 
the  bottom  of  the  laceration,  taking  care  to  penetrate  well  to  the 
base  of  the  angle  and  to  remove  all  of  the  connective  tissue.  The 
wound  is  smoothed  to  an  even  surface,  if  necessary,  with  the  curved 
scissors.  A  first  thread  is  then  passed  with  a  sti'ougly  curved 
needle  near  the  angle  of  the  wound.  The  tlu-ead  passes  through 
the  whole  thickness  of  the  lips,  at  two  millimeters  from  the  external 
surface  and  at  one  millimeter  from  the  internal.  It  is  better  to  tie 
each  suture  as  it  is  placed,  so  as  to  assure  perfect  coaptation.    Five 


130  Treatment  of  the  Metrites. 

to  six  sutures  are  tbiis  passed  successively.  I  use  catgut  as  it  has 
the  advantage  of  not  requii-ing  removal.  Two  sizes  should  be  at 
hand,  to  afford  some  fine  thi-eads  for  the  supplementary  sutures, 
which  are  especially  necessary  if  the  rupture  extends  to  the  vaginal 
cul-de-sac.  An  iodoform  tampon,  left  in  place  thi-ee  days,  comprises 
the  dressing.  After  this  time,  prescribe  antiseptic  vaginal  irri- 
gaions  morning  and  evening,  and  repose  in  bed  for  fifteen  days. 
When  the  laceration  is  bilateral,  it  is  almost  impossible,  in  making 
trachelorrhaphy  on  both  sides,  to  avoid  narrowing  the  cervical 
canal.  I  prefer  then  Schroeder's  operation,  as  it  is  in  these  con- 
ditions much  more  expeditious  and  permits  the  sclerosed  tissues  to 
be  removed  more  extensively.  After  all  operations  of  this  kind  it 
is  useful  to  explore  the  uterine  cavity  with  a  curette  and  if  the 
mucosa  is  soft  and  friable  to  remove  it  by  a  complete  curetting. 

Can  castration  be  legitimately  practiced  for  a  chronic  metritis  ? 
I  do  not  hesitate  to  respond  in  the  negative.  In  all  discussions  on 
this  subject  it  is  suiificient  to  carefully  analyze  the  cases  published 
to  see  that  castration  owes  its  incontestable  successes  to  the  fact 
that  it  has  been  dir-ected  much  less  against  the  uterine  lesion  than 
against  the  alterations  of  the  appendages  which  have  resulted  from 
inveterate  or  badly  treated  metritis.  In  these  conditions  the  me- 
tritis is  a  subordinate  condition  and  the  treatment  is  instituted 
against  a  complication  which  has  now  become  the  predominating 
morbid  element.  But  to  practice  at  once  ablation  of  the  ovaries 
and  tubes  on  the  sole  indication  of  painfiil  paroxysms  following 
upon  each  menstruation,  to  bring  about  an  artificial  menopause, 
is  a  misuse  of  the  operation. 

Pean'has  performed  vaginal  hysterectomy  several  times,  for 
painful  metritis,  belie-^dng  its  results  preferable  to  those  from 
removal  of  the  appendages.  He  recognizes,  however,  that  after 
the  ablation  of  the  uterus  it  may  be  necessary  to  open  the  abdomen 
for  removal  of  the  altered  appendages,  so  often  difficult  to  ac- 
complish through  the  vagina.  This  appears  to  me  only  to  prove 
that  the  supplementary  operation  should  have  preceded  the  princi- 
pal one  and  that  in  some  cases  the  removal  of  the  appendages 
might  have  been  sufficient.  Vaginal  hysterectomy  has  been  per- 
formed many  times  by  other  authors  for  obstinate  hiemorrhages  or 
painful  metritis.  This  certainly  has  been  a  mistake  in  many 
eases.  But  it  is  not  always  unjustifiable.  Eecent  researches  have 
demonstrated  that  metritic  glandular  hypertrophy,  which  resists  a 
seric^  of  curettings,  shows  by  this  fact  a  tendency  to  a  transfor- 
mation into  epithelioma. 


Fibroid  Tumors  of  the  Uterus.  131 


CHAPTER  VIII. 


FIBROID   TUMORS   OF   THE   UTERUS. 
PATHOLOGICAL  ANATOMY. 

The  names  fibromata,  fibrous  tumors,  myomata,  fibro-myomata, 
fibro-leio-myomata,  fibroids,  and  hysteromata,  have  been  given  to 
neoplasms  of  the  uterus  that  have  a  structure  resembling  that  of 
the  uterine  tissue  itself.  They  are  benign,  that  is  to  say,  not  sus- 
ceptible of  becoming  generalized  and  infecting  the  economy,  but, 
although  the  great  majority  pass  more  or  less  unnoticed  and  thus 
constitute  either  a  hidden  deformity  or  a  slight  infirmity,  there  is 
a  large  number  which  are  grave  and  death  may  result  from  the 
accidents  they  produce. 

Histogenesis. — Velpean-  and  a  number  of  authors  following 
him  have  attributed  the  development  of  fibrous  tumors  to  a  morbid 
change  resulting  from  the  presence  of  a  blood  clot  deposited  in  the 
uterine  tissue.  At  that  time  they  believed  in  the  spontaneous 
organization  of  the  clots  after  ligature  of  an  artery  and  applied  tliis 
idea  to  the  various  neoplasms.  Now  experimental  studies  have 
demonstrated  that  this  organization  of  the  clot  is  only  a  penetration 
by  the  growth  of  elements  coming  from  the  muscular  walls  and 
this  theoretic  edifice  is  completely  overthrown.  Krebs  claims 
that  the  genesis  of  the  fibro-myomata  has  for  its  origin  a  prolifer- 
ation of  the  connective  and  muscular  tissue  of  certain  vessels,  the 
different  nodules  thus  formed  becoming  agglomerated  to  produce  a 
tumor.  Kleinwachter  describes  the  evolution  of  the  fibroids  as  due 
to  the  species  of  round  cells  that  is  found  around  capillaries  which 
are  becoming  slowly  obliterated.  These  cells  are  first  transformed 
into  fusiform  bodies,  then  grouped  into  nodules.  In  short,  our 
knowledge  on  this  subject  is  still  but  little  advanced. 

These  neoplasms  are  very  frequent,  according  to  Bayle,  a.  fifth  of 
the  women  over  thirty-five  years  of  age  having  fibrous  tumors. 

Their  number  is  variable ;  in  some  eases  the  uterus  contains  a 
gTeat  number  of  small  tumors,  interstitial  or  pedunculated,  and 
presents  what  might  be  called  a  myomatous  degeneration.  More 
frequently  there  are  only  three  or  four  distinct  tumors.  Sometimes 
a  single  one  is  present,  yet  even  then  it  is  only  clinically  speaking 
that  there  exists  but  one  tumor.  It  is  rare  that  there  is  not  in  the 
thickness  or  at  the  surface  of  the  organ  another  small  nucleus, 
which  either  remains  latent  indefinitely  or  begins  to  grow  sooner  or 
later.     This  is  frequently  observed  in  laparotomies. 


132 


Fihru'ul  Tumors  <>f  the  Uterus. 


The  size  of  the  fibrous  body  may  attain  gi-eat  proportions.  It  is 
especially  in  the  case  of  fibro-cystic  growths  that  an  enormous 
weight  has  been  reported.     Even  solid  fibroids  aquire  gi'eat  size. 

The  body  of  the  uterus  is  more  j. 

frequently  attacked  than  is  the 
cervix.  According  to  its  situa- 
tion, relative  to  the  various  coats 
of  the  organ,  we  distinguish :  1. 
Interstitial  fibroids,  occupying 
the  thickness  of  the  muscular 
parenchyma.  2.  Submucous  fi- 
broids, immediately  under  the 
mucosa.  3.  Polypi,  or  peduncu- 
lated fibrous  bodies,  only  re- 
tained in  the  iiterine  cavity  by 
a  pedicle  formed  by  a  fold  of 
mucous  membrane,  some  mus- 
cular fibres  and  vessels.  4.  Sub- 
peritonaeal  fibroids  with  a  large 

,  ,  Fig.   62.  —  Small    interstitial    fibroid,     a. 

base  or  a  more  or  less  narrow  Walls  of  the  hypertrophied  uterus;  b,  fibroid; 
pedicle.  When  they  do  affect  c,  uterine  mucosa  affected  by  endometritis 
.,       ,  .....  and  polypoid  vegetations. 

the  form  of  polypi,  it  IS  not  con- 
venient to  give  them  that  name,  as  it  is  better  reserved  for  the 
variety  that  affects  the  uterine  cavity.     An  important  variety  of 


Fig.  63. — Submucous  fibroid  (cedematous)  with  hypertrophy 
of  the  w.ills  of  the  uterus. 


Fibroid  'Ihmiors  of  the  Uterus. 


183 


the  sessile  subperitoneeal  fibroids  is  that  wliich  develops  in  the 
thickness  of  the  broad  ligaments,  intra-ligamentous  fibroids.  But 
they  generally  proceed  from  the  cervix  and  will  be  described  with 
the  tumors  of  that  organ.  Whatever  their  situation,  they  provoke 
in  the  uterus  a  concomitant  hypertrophy  which  is  marked  in  various 


Fig,  64. — SubperitoiiiEal  and  interstitial  filjroi -is  of  ilie  fundus 


Fig.  65. — Interstitial  fibroids  of  the  fundus. 

The  muscular  wall  is  sometimes  so  thickened  as  to  enclose  the 
multiple  tumor  in  a  setting,  making  a  single  mass.  The  muscular 
layers  of  the  uterus  then  resemble  those  of  a  gravid  womb.  A  great 
vasculaj-  development  generally  accompanies  this  globular  hypertro- 
phy (Fig.  63).  The  increase  in  the  volume  of  the  uterus,  caused 
by  the  perpetual  excitation  in-oduced   by  the  neoplasm,  may  be 


134 


FUinnil   Tumors  of  the   Uterus. 


compared  to  that  of  the  organ  in  the  first  months  which  follow 
fecundation.  Very  smaU  fibromata  are  sufficient  to  produce  it 
(Fig.  62).  The  uterine  cavity  is  found  enlarged  by  this  eccentric 
dilatation,  and  often  besides  by  the  traction  on  the  fundus  of  a 
heavy,  and  sometimes  adherent,  mass. 


Fig.  66. — Uienne  polypus 


Fig.  67.— Subperitonseal  peundculated  fibroid  tumor. 

Fibromata  of  the  cervix  deserves  a  special  paragraph.  They  may 
affect  the  different  situations  that  have  been  indicated,  and  the 
same  divisions  apply.  But  the  separation  of  the  eer^dx  into  two 
distinct  regions  imposes  another  classification,  intravaginal  and 
supravaginal. 

A. — Intraraginal. — Whether  interstitial  or  submucous  they  give 
to  the  lip  of  the  cervix,  in  which  they  develop,  a  more  or  less 


Fibroid  Tumors  of  the  Uterus. 


135 


cylindrical  and  elongated  form.  Thus  they  may  fill  the  whole 
vagina  (Fig.  68).  Submucous  fibromata,  arising  in  the  cervical 
cavity,  effect  a  polypoid  character.  At  times  these  small  fibrous 
polypi  of  the  cervix  contain  a  layer  of  glandular  neoformatiou  and 
present  a  papillary  appearance  (Fig.  69).  Exceptionally  fibro- 
mata arising  in  the  body  of  the  uterus  descend  into  a  lip  of  the 
cervix. 


Interstitial  fibroid  of  the  posterior  lip  of  the  cervix. 

B. — Supravaginal. — The  only  ones  which  deserve  mention  are 
those  which  arise  from  the  external  sui-face  of  the  region,  and  are 
thus  found  at  first  in  the  tissues  of  the  pelvic  floor,  remaining 
incarcerated  in  the  pelvis.  They 
develop  most  frequently  behind  the 
cervix  pushing  aside  Douglas'  cul- 
de-sac  to  come  in  contact  with  the 
posterior  wall  of  the  vagina  and 
with  the  rectum.  They  often  push 
between  the  folds  of  the  broad  hga- 
ments  at  each  side,  thus  consti- 
tuting one  of  the  most  dangerous 
varieties  of  the  intra-ligamentous 
fibromata.  They  may  even  pass 
this  region  burrowing  between  the 
uterus  and  the  bladder,  throwing 
out  prolongations,  as  far  as  the 
iliac  meso-colon.  Imprisoned  as 
they  are,  by  their  origin  in  the 
cavity  of  the  bony  pelvis,  they  cause  all  the  accidents  of  com 
pression.     I  have  proposed  calling  them  pelvic  fibromata. 


Fig.  69. — Small  polypus  of  the  cervix 
(papillary  fibroma  with  hypertrophy  of 
the  glands).     (Ackermann.) 


136 


F'lhro'id   Tiiinnr.'i  of  the   I'lcniH. 


Co7ineetionis  of  jihrumata  with  uterine  tissue. — Generally  the  fibro- 
mata are  separated  from  the  uterine  tissues  by  a  zone  of  loose 
connective  tissue  forming  a  capsule,  from  which  they  can  be 
enucleated  with  little  effort.  This  disposition  is  sometimes  so 
marked  that  simple  incision  of  the  capsule  will  cause  the  tumor  to 
roll  out  of  its  bed  under  the  influence  of  muscular  contractions. 
But  more  frequently  this  independence  is  not  complete,  and  the 
fibroma,  in  place  of  being  enclosed  in  the  uterine  parenchyma  like 
a  simple  foreign  body,  is  retained  by  more  or  less  dense  fibrous 
bundles,  which  also  establish  vascular  connections.  Finally,  there 
exist  rare  cases  in  wliich  there  is  no  appreciafljle  demarkation 
between  the  fibroma  and  the  uterine  wall. 


Fig.  70. — Intra-ligamentous  fibroid.     A.  Abdominal  variety.     B.   Pelvic  variety. 

Structure  and  teoctv/re. — To  the  naked  eye  fibrous  tumors  are 
constituted  by  a  dense,  white,  or  rosy-white,  elastic  tissue,  giving 
either  a  clear  or  unequal  section,  shghtly  convex.  With  the  help 
of  a  lens  there  can  ))e  distinguished  at  the  surface  interlacing  fibres 
and  vortices,  as  if  the  fibres  were  wound  around  multiple  axes 
(Fig.  71).  The  vessels  are  relatively  few.  However,  in  very  large 
fibromata,  they  are  sometimes  seen  extensively  ramifying  over  the 
surfaces,  under  the  peritouieum  or  in  the  capsule.  In  one  case  I 
observed  a  bloodvessel  of  the  broad  ligament  of  the  calibre  of  the 
brachial  artery  which  gave  rise  to  a  very  loud  thrill.  The  peripheral 
veins  may  have  the  volume  of  the  jugular  and  be  adherent  in  all 
parts  to  the  muscular  fibres.  When  this  disposition  is  marked  and 
when  the  neoplasm  possesses  a  multiple  of  vascular  lacunae  due  to 
dilated  capillaries  they  belong  to  the  variety  described  by  Virchow 
as  telangiectasic  myomata  (myoma  telangiectodes,  seu  cavernosum). 
The  portions  thus  degenerated  resembles  a  sponge  filled  with  blood. 


Fibroid  Tumors  of  the   Uterus. 


137 


In  polypi  the  pedicle  rarely  contains  large  arterial  vessels.  Even 
when  they  do  exist,  the  thickness  of  the  vessel  wall  and  their 
retractility,  added  to  the  contractility  of  the  pedicle  itself,  assure 
rapid  spontaneous  hsemostasis  when  the  pedicle  is  divided.  The 
spaces  which  divide  the  gi-oups  of  fibres  are  considered  by  Klebs  as, 
lymphatic  spaces.  Nerves  have  been  traced  into  these  tumors  by 
Astruc  and  Dupuytren.  Bidder  has  lately  demonstrated  their 
presence  and  Hertz  has  even  described  their  mode  of  termination 
in  the  nuclei  of  the  smooth  fibres. 

Fibrous  tumors,  examined  under  the  microscope,  present  non- 
striated  muscular  fibres  and  con- 
nective tissue  fibres  in  variable  pro- 
portions. According  to  Eobin  the 
muscular  fibres  never  constitute 
more  than  half  and  sometimes  only 
one-tenth.  According  to  the  pre- 
domination of  one  or  the  other  of 
these  varieties  of  fibres  these 
tumors  have  been  divided  into 
fibromata,  myomata  and  fibro-my- 
omata.  This  last  term  is  the  only 
exact  expression,  for  these  elements 
are  almost  always  mixed.  Gusse- 
row  proposes  to  distinguish  the 
hard  fibromata,  in  which  connec- 
tive-tissue fibres  predominate,  and 
soft  fibromata,  which  are  especially 
muscular.  The  last  are  less  clearly  encapsulated  and  more  vascular. 
Generally,  in  section,  the  mucular  fasciculi  and  the  fibres  of  con- 
nective tissue  are  seen  cut  transversely,  obliquely,  or  even  in  their 
whole  length.  The  first  are  easily  distinguished  by  the  fusiform 
aspect  of  their  elements  and  by  their  characteristic  nuclei,  which 
the  transverse  section  shows  in  a  mosaic.  This  horizontal  section 
of  the  fibres  and  their  nuclei  may  be  confused  with  the  projection 
of  a  round  cell.  Between  these  fasciculi  exist  the  fibrous  tissues, 
unequally  thickened  and  interlaced  in  different  directions.  They 
are  composed  in  part  of  fasciculi  of  connective-tissue  fibres,  poor 
in  cells,  in  part  of  fasciculi  of  fusiform  bodies  with  long  branches. 

Connections  with  neighbori^ig  organs. — When  a  fibroid  tumor  arises 
by  a  broad  base  from  a  free  part  of  the  uterus,  fundus,  anterior  or 
posterior  surface,  it  extends  into  the  abdominal  cavity  above  the 
superior  strait  and  floats  in  the  midst  of  the  intestinal  mass.  The 
uterus  is  enlarged  upward  and  sometimes  drawn  upward,  the  cervix 
is  thinned  and  the  cavity  elongated.  If  the  origin  of  the  fibroid 
is  narrow,  the  uteras  no  longer  serves  as  a  support.  It  may  fall 
into  Douglas'  cul-de-sac  and  become  fixed  there,  with  or  without 


Fig.  71. — Fibroid  tumor  of  the  uter- 
us. Section  showing  the  disposition  of 
fibres  as  seen  by  the  naked  eye. 


138 


Fibroid  Tumors  of  the  Utents. 


adhesions.  If  it  becomes  large,  without  beeomiug  fixed,  it  will  float 
up  into  the  abdominal  cavity,  irritating  the  peritonaeum  until  it 
causes  an  exudation,  either  ascitic  or  plastic.  The  ascites  is  gener- 
allj'  of  small  quantity,  of  lemon-colored  liquid,  rarely  tinged  with 
blood,  the  latter  condition  being  more  frequently  found  in  malig- 
nant tumors.  A  chylous  ascites  has  also  been  observed,  probably 
from  the  transformation  of  fibrinous  exudates. 


Fig.  72. — Fibro-myoma  of  the  uterus.     Microscopic  appearance  of  a  section. 

The  adhesions  generally  take  place  with  the  great  omentum  or 
with  the  intestine.  The  intestinal  loop  is  sometimes  so  nearly 
fused  with  the  surface  of  the  fibroid  as  to  defy  dissection.  These 
adhesions  then  become  the  principal  source  of  nutrition  for  the 
neoplasm  and  the  pedicle  may  become  extremely  thin  without  ces- 
sation of  the  gi-owth  of  the  tumor.  The  pedicle  may  even  be 
broken  and  leave  the  fibrous  body  independent  of  the  uterus, 
grafted  on  some  point  of  the  pelvic  contents.  Elongation  and 
torsion  of  the  pedicle  may  also  produce  changes  in  the  nutrition  of 
a  fibroid,  leading  to  consecutive  degeneration. 

Alterations  and  degenerations  of  neoplasms. — The  majority  of  fibro- 
mata undergo  a  progi'essive  induration  from  the  time  of  the  meno- 
pause. At  the  same  time  they  decrease  in  size  and  the  litems 
presents  senile  involution  and  atrophy.  The  tumor  still  remains 
but  without  causing  any  morbid  reaction.  Such  is  the  condition 
of  many  of  the  fibromata,  uni-ecoguized  during  life,  that  are  found 
in  the  autopsies  of  old  women. 

Calcification  (not  ossification)  is  a  somewhat  rare  condition.  The 
deposits  of  the  phosphate  and  carbonate  of  lime  take  ijlace 
especially  in  the  center  of  the  tumor  and  form  either  an  incomplete 
structure  or  true  uterine  calculi.  They  are  scarcely  ever  observed 
except  in  the  subserous  pedunculated  fibromata  or  in  the  polypi. 
Softening  may  arise  from  two  causes.  During  pregnancy  fibroids 
acquire  a  considerable  size,  as  they  participate  in  the  exaggerated 
nutrition  of  the  uterus.     Thus  swollen  thev  are  generallv  softer 


Fibroid  Tumors  of  the  Uterus. 


139 


after  parturition.  By  a  process,  Avhich  has  been  somewhat  hypo- 
thetically  attributed  to  fatty  degeneration,  they  may  disappear  by 
degrees,  participating  thus  in  the  invohition  of  the  uterus.  Fatty 
degeneration  has  never  been  found  microscopically  except  in  two 
cases,  where  diminution  of  the  tumor  had  not  resulted.  Amyloid 
degeneration  has  been  observed  by  Stratz  in  a  polypus:  This  case 
is  unique.  CEdema,  which  is  the  first  stage  of  mortiiication,  may 
cause  softening  of  the  fibroid  tumor.  Colloid  or  myxomatous 
degeneration  is  characterized,  according  to  Virchow,  by  the  effusion 
of  a  mucous  material  between  the  muscular  fasciculi.  It  is  dis- 
tinguished from  simple  cedema  by  the  presence  of  mucine  and  the 
proliferation  of  nuclei  and  of  round  cells  in  the  interstitial  tissue. 


Fig.  73. — Pedunculated  fibroid  of  abdominal  evolution.     MS,  fibroma  of 
lobe;   MC,  fibro-cystic  lobe.     (Schroeder.) 

The  formation  of  fibro-cystic  tumors  may  succeed  to  any  one  of 
these  infiltrations  when  the  meshes  which  separate  the  small  cells 
of  the  oedema  are  destroyed.  There  is,  then,  no  distinct  wall  to 
these  cysts,  as  they  are  simply  made  up  of  the  lacunfe  of  the 
tissues  of  the  tumor.  Fibro-cystic  tumors  have  a  very  different 
origin  from  other  growths  and  belong  to  a  special  anatomo-patho- 
logical  species.     The  cysts  occur  in  preformed  cavities  that  are 


140  Fihrn'td  Tiimitra  of  thr  TVovis. 

clilatatious  of  the  lymphatic  vessels  comijarable  to  those  sometimes 
attaiuecl  by  the  bloodvessels.  The  contained  liquid  is  limpid  and 
coagulates  on  exposure  to  air.  Leopold  has  caDed  them  lymphan- 
giectasic  uiyomata.  On  the  internal  surface  of  these  lymphatic 
cysts  there  exist  an  endotheUal  lining,  which  distinguishes  them 
from  the  simple  cavities  formed  by  softening  of  the  neoplasm  or  by 
hiemorrhage  into  its  thickness.  Mixed  forms  are  observed,  both 
telangiectasic  and  lymphangiectasic.  It  is  essential  not  to  confound 
tibro-cystic  tumors  of  the  uterus,  either  with  intra-ligamentous 
ovarian  cysts,  very  adherent  to  the  uterus,  or  ^nth  the  accumu- 
lations of  serum  that  are  sometimes  found  in  the  foci  of  pelvic 
peritonitis  around  that  organ.  This  mistake  has  been  made  more 
than  once. 

Finally  some  pseudo-cysts  are  formed  by  the  foci  of  molecular, 
granulo-fatty  degeneration,  which  may  be  produced  in  the  center 
of  large  tumors  when  the  nutrition  is  impaii-ed.  The  mortification 
may  not  be  followed  by  gangi-ene,  because  of  the  absence  of  germs. 
There  is  then  produced  a  necrobiosis,  Avith  the  formation  of  soft 
masses,  falling  later  into  dehquescence  and  constituting  cavities 
with  more  or  less  liquid  contents.  Sanguineous  effusions  often 
increase  the  dimensions  of  these  false  cysts.  Eupture  of  such  a 
focus  into  the  uterus  has  been  noted.  In  some  rare  cases,  in  which 
there  is  obliteration  of  the  uterine  orifice  through  elongation  of  the 
cervix,  partial  rotation,  or  inflammation,  a  special  haematometra 
occurs. 

By  way  of  resume  it  ^^"ill  be  seen  that  from  an  anatomical  point 
of  view  the  myo-  or  the  fibro-cystic  tumors  do  not  constitute  a 
natural  gi'oup.  We  may  recognize,  as  to  origin:  1.  Closed  spaces, 
resulting  from  the  dilatation  of  the  lymphatics,  lymphangiectasis. 
•2.  GEdematous  and  myxomatous  infiltrations,  in  the  last  stage.  3. 
Lacuna?  formed  in  the  center  of  tumors  by  the  disintegi-ation  of 
the  tissue,  myomata  or  sarcomata.  Hfemorrhagic  foci  may  com- 
phcate  these  conditions. 

Injiammat'w)! ,  suppuration ,  (jatKjrene. — It  is  probable  that  the  origin 
of  inflammation  in  fibromata  is  always  a  more  or  less  extended  loss 
of  ^■itality  which  infects  the  capsule  and  provokes  a  supjjuration  in 
this  zone  where  the  tissue  is  at  once  more  vascular  and  more  lax. 
This  initial  death  is  due  either  to  surgical  interference,  opening  the 
capsule  of  the  tumor  as  a  therapeutic  procedui-e,  or  to  an  infection 
from  without  in  consequence  of  a  septic  exploration  (dilatation, 
probing).  It  may  also  proceed  from  the  compression  or  the  obhter- 
ation  of  the  nuti'itive  vessels,  together  with  an  erosion  of  the  mucosa 
which  covers  it  and  protects  against  the  entrance  of  germs.  It  is 
especially  in  polypi  that  tliis  last  mode  of  gangrene  is  observed. 
If  it  is  true  that  the  death  of  a  small  portion  of  an  interstitial  or 
of  a  submucous  filn-oid  precedes  inflammation  and  suppuration,  it 


Fibroid  Tumors  of  the  Uterus.  141 

is  also  true  that  these  are  in  their  turn  the  causative  agent  of  the 
gangrene  of  the  whole  mass.  The  sloughing  parts  are  eliminated 
spontaneously  or  with  the  aid  of  surgical  interference ;  but  they 
may  also  cause  a  putrid  infection.  The  pus  may  then  extend  into 
the  pelvic  cellular  tissues. 

Cancerous  degeneration. — Can  a  fibroid  become  the  starting  point' 
of  a  cancer  ?  Simpson  has  maintained  that  the  irritation  caused 
by  the  presence  of  the  fibroid  becomes  the  starting  point  for  a 
malign  growth.  To-day  we  express  the  same  idea  by  saying  that 
this  presence  constitutes  a  locus  minoris  resistentice,  causing  the  local 
determination  of  the  diathesis.  Eecent  researches  have  permitted 
an  exact  statement  of  the  processes.  It  is  probable  that  in  certain 
cases  it  is  the  chi-onic  inflammation  of  the  mucosa,  usually 
accompanying  the  fibroid,  that  causes  first  a  proliferation  of  the 
glands.  This  passes  from  the  typical  form,  adenoma,  to  the 
atypical  form,  epitheloma.  A  second  mode  of  transformation  of 
the  fibroid  into  cancer  is  sarcomatous  degeneration  of  the  connective 
tissue  frame-work  itself,  by  infiltration  -wdtli  round  cells.  It  is 
possible  that  these  myosarcomata  undergo  cystic  transformation, 
either  by  distention  of  the  lymphatic  spaces  or  by  softening  and 
hsemorrhagic  effusions.  They  produce  then  a  sarcomatous  variety 
of  fibro-cystic  tumors.  With  regard  to  carcinomatous  degeneration 
of  fibroid  tumors  of  the  uterus,  the  researches  by  Gusserow 
show  that  it  is  far  from  being  demonstrated.  The  observations 
which  have  been  cited  generally  relate  to  cases  where  carcinoma 
has  invaded  the  uterus  by  the  side  of  fibromata,  very  different  in 
a  pathogenetic  and  anatomo-pathological  point  of  view,  although 
very  analogous  in  the  clinical.  C.  Liebman  has  published  a  case 
in  wliicli  the  carcinomatous  degeneration  appeared  certain.  There 
was  at  the  same  time  cancer  of  the  two  ovaries.  The  association 
of  cervical  epithelioma  with  fribromata  of  the  body  is  quite  frequent. 

Contiguous  and  distant  lesions. — Endometritis  exists  in  almost 
every  case  of  fibroid.  The  mucosa  of  the  uterus  undergoes  an 
interstitial  or  glandular  hyperplasia.  Wyder  has  observed  that  this 
last  is  met  almost  exclusively  in  fibromata  quite  distinct  from  the 
uterine  cavity,  wliile  the  interstitial  form  accompanies  the  fibroids 
that  are  not  distant  from  the  mucosa.  A  mixed  form  is  also  observed 
sometimes.  These  lesions  account  for  the  haemorrhages  sympto- 
matic of  the  fibromata.  An  endo-salpingitis  often  exists  by  extension 
of  the  disease.  Rosa,  in  the  course  of  a  myomotomy,  found  an 
hsematoma  of  the  tube  which  had  so  thinned  this  organ  that  perfo- 
ration was  imminent. 

Bantock  has  often  found  a  fatty  liver  among  patients  affected  by 
large  fibromata  and  he  attributes  this  lesion  to  the  presence  of  the 
tumor.  Fibroid  tumors,  by  compressing  the  ureters,  often  prodiice 
serious  kidney  troubles.     The  lesions  of  the  heart,  which  occur  in 


142  Fibroid  Tudujvs  oJ  the   Uterus. 

all  large  abdominal  tumors,  are  frequently  a  complication  of  uterine 
fibroids.  They  sometimes  appear  associated  with  a  renal  trouble, 
but  tills  correlation  is  not  always  found.  The  cardiac  hypertrophy, 
with  or  without  dilatation  of  the  cavities  or  consecutive  alteration 
of  the  fibres,  have,  without  doubt,  a  pathogeny  analogous  to  that 
which  cause  hypertrophy  during  pregnancy.  With  regard  to  the 
tiltimate  degeneration  of  the  heart,  it  is  greatly  favored  by  the 
state  of  anaemia  and  the  cachexia  of  some  subjects. 


CHAPTER  IX. 


FIBROID  TUMORS  OF  THE  UTERUS.— SYMPTOMS, 
DIAGNOSIS,  AETIOLOGY. 

The  symptoms  of  uterine  fibromata  are  of  two  varieties  :  1.  The 
rational  symptoms  which  reproduce  the  uterine  group  of  symptoms 
have  been  described,  with  some  special  peculiarities  and  with  the 
predominance  of  the  symptom,  haemorrhage.  2.  The  physical  signs 
arising  from  the  presence  of  the  tumor. 

1.  Rational  symptoms. — The  developments  into  which  I  entered 
in  the  discussion  of  the  uterine  group  of  symptoms  permit  abridge- 
ment of  the  description  of  these  symptoms.  The  haemorrhages  are 
especially  marked  here  and  become  the  predominating  symptom  in 
the  majority  of  cases.  They  occur  as  menorrhagias  or  metror- 
rhagias. They  are  intimately  associated  with  the  lesions  of  inter- 
stitial metritis  which  always  accompany  the  fibromata  that  are  a 
little  distant  from  the  mucosa.  The  glandular  metritis,  which 
coexists  with  the  fibromata  that  are  more  distant,  only  give  rise  to 
leucorrhoea.  In  general,  the  htemorrhage  is  more  marked  in 
proportion  as  the  neoplasm  approaches  the  uterine  cavity.  It 
attains  its  maximum  in  polypi.  These  losses  of  blood  weaken  the 
patient  very  much  but  eases  of  death  are  exceptional.  In  one 
autopsy,  reported  by  Matthews  Duncan,  a  large  uterine  sinus  was 
found  ruptured. 

Leucorrhoea  is  usual.  Sometimes  there  is  an  abundant  flow  of  a 
serous  nature,  but  distinguished  from  that  of  cancer  by  the  absence 
of  odor  and  by  its  intermittent  character. 

The  pains  are  of  various  kinds.  Usually  there  exists  a  painful 
sense  of  weight,  of  lumbar  dragging,  so  frequent  in  all  uteruie 
affections.  To  this  is  added,  in  tumors  which  project  into  the 
uterine  cavity,  colic  or  expulsive  pains,  sometimes  very  severe  at 


Fibroid  Tuviors  of  the  Uterus.  143 

the  menstrual  period.  Some  large  tumors,  by  pressure  on  the  sacral 
plexus,  cause  sciatica.  These  pains  are  intermittent  and  particu- 
larly severe  at  the  time  of  the  menses. 

The  phenomena  of  compression  are  very  frequent,  as  regards  the 
bladder.  It  is  especially  at  the  monthly  period  that  the  vesical 
troubles  are  pronounced.  They  sometimes  assume  the  importance 
of  true  cystitis  by  retention  of  urine.  The  compression  of  the  neck 
of  the  bladder  may  produce  a  chronic  distention  of  the  organ,  which 
has  been  mistaken  for  an  ovarian  cyst. 

The  pressure  upon  the  rectum,  less  frequent  than  that  of  the 
bladder,  sometimes  causes  hsemorrhoids  and  unites  its  influence 
with  that  of  the  habitual  dyspeptic  in  producing  constipation. 
Barnes  attributes  a  great  importance  to  the  resorption  of  excre- 
mentitious  material  which  follows  obstinate  constipation,  calling 
its  result  copraemia.  The  recent  researches  on  ptomaines  and 
leucomaines  give  a  certain  weight  to  this  opinion.  In  fibroids  fixed 
in  the  pelvic  cavity  the  pressure  upon  the  rectum  may  cause  a 
strangulation  leading  to  death. 

The  compression  of  the  ureters  and  the  serious  renal  troubles 
that  this  causes  become  an  important  indication  for  operation.  A 
very  great  number  of  the  deaths  in  consequence  of  hysterectomy 
or  of  castration  should  be  attributed  to  pathological  changes  in  the 
kidneys,  often  unrecognized,  Avhieh  the  surgical  interference  and 
the  long  inhalation  of  antesthetics  have  aggravated.  On  the  con- 
trary, suppurating  pyelitis  and  albuminuria,  with  threatening 
symptoms  of  ursemia,  have  been  seen  to  disappear  after  the  ablation 
of  a  fibroid  that  compromised  the  ureters. 

Every  abdominal  tumor  is  the  cause  of  an  increase  of  vaScular 
pressure  and  consequently  reacts  on  the  cardiac  muscle.  It  is  not 
astonishing  then  that  even  a  slight  heart  lesion  may  be  aggravated 
by  the  presence  of  a  fibroma.  A  part  of  the  diseases  of  the  heart 
observed  in  patients  affected  with  large  fibromata  have  this  origin. 
But  this  complication  is  too  frequent  to  receive  a  similar  interpre- 
tation in  every  case.  Hofmeier  relates  a  series  of  eighteen  cases 
in  which  sudden  death  by  arrest  of  the  heart  was  caused  by  an 
abdominal  tumor.  In  three  cases  there  was  advanced  fatty 
degeneration  of  the  cardiac  fibre.  In  fifteen  cases  there  was  brown 
atrophy  of  the  heart.  Five  deaths  occurred  before  any  operation, 
nine  after  an  operation,  and  five  after  accouchement.  Auscultation 
should  then  be  made  with  great  care  in  every  patient  affected  by  a 
fibroid  tumor  of  a  certain  volume.  I  agree  with  those  surgeons  who 
see  in  tliis  lesion  a  new  indication  for  operation  and  at  the  same 
time  a  grave  element  in  prognosis. 

Among  the  signs  furnished  by  local  examination,  the  increase  in 
the  length  of  the  uterine  cavity  should  be  placed  in  the  first  rank 
as  the  most  constant,  being  common  to  both  large  and  small  tumors. 


144  FUiroid  Tumors  </f  the   Uterus. 

It  is  constant  in  all  cases  of  tumors  in  the  process  of  evolution, 
that  is  to  say,  giving  rise  to  niorhid  phenomena.  The  uterus  is 
dilated  in  interstitial  fibroids  as  well  as  in  small  polypi,  because 
it  is  hypertropliied  under  the  influence  of  what  Guyon  has  called 
the  til  irons  pregnancy.  In  the  large  fibromata  the  uterus  is  also 
elongated  by  the  eccentric  development  of  the  tumor  by  the  traction 
on  the  cervix.  The  sound  may  then  penetrate  even  to  twenty 
centimetres.  This  iise  of  the  sound  should  always  be  practiced 
with  great  care.  It  is  usually  possible  to  employ  the  sound  of 
malleable  silver,  but  in  difficult  cases  recourse  may  be  had  to  a 
flexible  urethral  bougie.  The  cavity  may  also  be  so  effaced  by 
the  projection  of  the  fibroid  that  no  sound  can  be  passed. 

Exploration  of  the  tumor  should  be  made  by  bimanual  exami- 
nation aided  by  rectal  touch.  In  difficult  cases  it  may  be  useful 
to  have  recourse  to  anaesthesia  to  relax  the  uterine  walls.  One 
general  remark  applies  to  all  the  examinations :  They  furnish  a 
varying  degi'ee  of  information  according  as  they  are  made  during 
or  after  an  ha?morrhagic  period.  In  the  second  case,  a  very  great 
diminution  in  the  volume  of  the  tumor  is  found,  thus  often  giving 
rise  to  illusions  as  to  the  efficacy  of  internal  treatment.  It  is  also 
necessary  to  be  suspicious  of  the  apparent  contractions  that  have 
been  felt  in  some  tumors ;  a  fibrillary  movement  of  the  abdominal 
wall,  the  displacement  of  an  intestinal  loop,  may  give  rise  to  this 
illusion.  When  the  tumor  has  effaced  or  passed  the  cei-vix  it  is 
accessible  to  vaginal  examination. 

Diagnosis.  — Clinically,  fibroids  should  be  divided  into  thi-ee 
classes  (which  again  have  subdivisions) :  1st.  Those  in  which  the 
tumor,  but  little  developed,  constitutes  a  symptom  of  moderate 
gravity;  or  2d  and  3d,  those  in  which  it  is  well  marked  and 
pursues  an  evolution  toward  the  peritonaeal  cavity. 

In  the  first  case,  the  predominant  sjTnptoms  are  those  of  sympto- 
matic metritis,  metritic  type.  In  the  second  case,  type  of  vaginal 
evolution,  there  are  the  secondary  divisions  formed  by :  (a).  Sub- 
mucous fibroids  of  the  body ;  (b ) .  Pedunculated  fibroids,  or  polypi ; 
(c).  Fibroids  of  the  infi-avaginal  portion  of  the  cei-vix.  In  the  third 
case,  type  of  abdominal  evolution,  it  is  important  to  separate  :  (a). 
Pedunculated  fibromata ;  (b).  Those  developed  in  the  fundus  of 
the  uterus  above  the  point  of  attachment  of  the  broad  ligaments ; 
(e).  Those  developed  in  the  body  of  the  organ  below  the  attachment 
of  the  broad  ligament,  and  among  these  are  those  tumors  which 
arise  under  the  iieritonfeum  in  the  supravaginal  poi^tion  of  the 
cervix,  or  of  pelvic  development  in  the  cellular  tissues  of  the  pelvic 
cavity. 

The  following  table  gives  this  division  at  a  glance  : 
I.  Metritic  t>'pe  (small  interstitial  fibroidj. 


Fibroid  Tumors  of  the  Uterus.  145 

f  A.  Fibroids  of  the  infravaginal  part  of  /  Sessile. 

I  tlie  cervix.                                       \  Pedunculatea. 

B.  Submucous  fibroids  (of  tlie  body). 

II.  Type  of  vaginal  evolution -{  C.  Fibroids    (of    the     f(a).  Intrauterine. 

I  body),  polypi  or  J  (b).  Presenting  intermittently. 

I  pedunculated  fi- 1  (c).  Intravaginal. — 

[  broids.  [  var.  enormous  polypi. 

f  A.  Pedunculated  fibroids. 

TTT    T  r    uj       ■     I        It-         B.  Sessile  fibroids,  not  included  in  the  broad 

III.  Type  of  abdominal  evolution  ,.  ^        ' 
C    K      >     ,    1      •   fp  ttt'  ]\  ■{             ligaments. 

^       '^      '  "      '     '  j  C.  Sessile  fibroids  included  in  the  f  Abdominal. 

I  broad  ligaments.  \  Pelvic. 

I.  Diagnosis  of  fibroids  of  metritic  type  (small  interstitial 
fibroids). — When  the  tumor  is  small  and  has  not  yet  separated  the 
walls  of  the  uterus  (Fig.  62),  it  is  sometimes  difficult  to  recognize 
the  true  origin  of  the  symptoms  observed.  The  guiding  symptoms 
then  will  be  the  persistence  of  haemorrhages  coincident  with  an 
increase  in  the  volume  of  the  uterus,  the  enlargement  of  its  cavity 
and  the  presence  of  a  tumor  when  it  can  be  found.  Thus  htemor- 
rhagic  metritis  will  be  excluded.  The  beginning  of  pregnancy  is 
characterized  by  the  absence  of  the  menses;  here  the  occasional 
eases  in  which  menstruation  persists  should  be  remembered.  Mis- 
carriage with  retardation  of  uterine  involution,  caused  by  a  partial 
retention  of  the  placenta,  is  distinguished  by  its  special  course  as 
well  as  by  the  study  of  the  products  expelled  or  furnished  by  the 
curette.  Cancer  of  the  body  of  the  uterus  gives  rise  also  to 
haemorrhages  and  to  increase  in  the  size  of  the  organ,  but  these 
symptoms  are  accompanied  by  fetid  leucorrhoea,  and,  in  doubt, 
microscopic  examination  of  a  fragment  removed  by  the  curette  will 
determine  the  natu.re  of  the  disease. 

Inflammations  of  the  tubes  and  ovaries  are  a  very  frequent  cause 
of  error,  especially  from  the  misleading  fact  of  frequent  haemor- 
rhages and  the  tumor  (hygro-,  haemato-  or  pyo-salpinx)  which  often 
appears  as  a  part  of  the  uterus,  either  at  the  side  or  behind  in 
Douglas'  cul-de-sac.  Fluctuation  must  be  sought  for  to  clear  up 
the  diagnosis.  It  is  generally  wanting  in  small  tense  tumors  and 
besides  it  is  dangerous  to  seek  for  it  Avith  too  much  persistence. 
The  very  great  rapidity  of  the  formation  of  the  tumor,  the  history, 
the  rational  signs,  minute  local  examination  under  anaesthesia,  the 
absence  of  increase  in  the  length  of  the  uterine  cavity,  will  be 
valuable  signs  in  the  recognition  of  an  affection  of  the  appendages. 

Anteflexion  and  retroflexion  of  the  uterus,  even  when  accom- 
panied by  hfemorrhages,  will  not  be  long  in  doubt.  The  nature  of 
the  tumor  that  is  felt  in  one  of  the  vaginal  culs-de-sac  Avill  be 
quickly  recognized  by  bimanual  examination  and  by  the  sound.  I 
only  mention  the  small  faecal  tumors  that  accumulate  in  the  rectum 
and  confuse  the  young  practitioner.  They  are  compressible  to  the 
finger  and  a  rectal  enema  causes  their  disappearance. 


146  Fibroid  Tumors  of  the  Uterus. 

II.  Diagnosis  of  fibroids  of  vaginal  evolution. — A.  Of 

the  infrardijinal  portion  <f  the  rrrrlr. — The  existence  of  a  tumor 
depending  from  one  lip  of  the  uervix  is  here  the  principal  symptom. 
This  tumor  is  smooth,  elastic,  ordinarily  not  ulcerated.  By  passing 
a  finger  around  its  base  the  os  uteri  is  felt  in  front  of  it  or  behind 
it,  the  healthy  lip  is  generally  tliinned  and  somewhat  effaced.  This 
fact  has  caused  some  error,  by  suggesting  an  inversiou  of  the  uterus 
or  a  polypus  from  the  cavity.  Attentive  examination  of  the  cer^ix 
by  touch,  of  the  uterus  by  the  sound  and  of  the  situation  of  the 
organs  by  bimanual  exploration  "will  be  sufficient  to  set  aside  these 
errors.  It  should  not  be  forgotten  that  even  a  fibroid  of  the 
cervix  may  be  pedunculated.  They  may  also,  when  arising  at  the 
insertion  of  the  vagina,  fold  up  the  recto- vaginal  septum  so  as  to 
simulate  a  vaginal  tumor.  Finally  they  may  develop  in  part 
toward  the  uterine  cavity. 

B.  Suhmueous  fibroids  of  the  body  of  the  uterus. — The  hiemorrhagic 
accidents  and  the  increase  of  the  uterme  cavity  are  here  promi- 
nently marked.  The  presence  of  the  tumor  is  also  of  easy 
demonstration.  Examination  for  tliis  should  be  practiced  during 
the  haemorrhages,  while  the  uterine  contractions  soften  and  open 
the  cervical  cavity.  If  required,  active  dilatation  may  be  used  to 
permit  exact  diagnosis  by  intrauterine  touch.  There  is  then  felt 
on  one  of  the  surfaces  a  tumor  which  projects  into  the  cavity  and 
reduces  it  to  a  narrow  slit.  The  surface  of  the  tumor  covered  by 
the  mucous  membrane  is  smooth.  It  has  no  pedicle,  but  an  im- 
plantation by  a  large  base,  excluding  the  idea  of  a  polypus.  On 
its  external  surface  the  uterus  has  in  this  case  a  globular_form 
which  might  lead  to  the  idea  of  pregnancy  were  it  not  for  the 
haemorrhages,  so  exceptional  in  the  latter.  It  is  when  the  surface 
of  these  myomata  is  the  seat  of  sloughing  that  errors  of  diagnosis 
are  possible ;  the  sanious  discharge,  the  irregular  and  putrid 
surface,  the  cachexia  of  the  patient  may  lead  to  the  diagnosis  of  a 
malignant  tumor. 

C.  Pedunculated  fibroids  or  polypi  of  the  body. — The  evolution  of 
polypi  may  be  divided  into  thi-ee  periods :  in  the  fii'st,  the  peduncu- 
lated fibroid  is  still  enclosed  in  the  cavity  of  the  uterus,  which  is 
often  much  dilated,  it  is  intrauterine.  In  the  second  stage  there  is 
a  tendency  to  push  thi-ough  the  cervix,  it  passes  the  external  os  at 
the  menstrual  period  and  disappears  during  the  intervals,  this  is 
the  variety  with  intermittent  presentation.  Finally,  in  the  third 
period,  the  last  stage  of  their  evolution,  the  polj-pi  pass  out  of  the 
uterus  becoming  iutravaginal.  They  may  then  take  on  a  very 
great  development,  becoming  enormous  in  size  constituting  again 
a  new  variety,  in  a  clinical  point  of  view.  Intrauterine  polypi  can 
be  distinguished  from  sessile  submucous  fibroids  only  by  direct 


Fihroid  Tumors  of  the  Uterus.  147 

exploration  after  dilatation.  The  existence  of  a  pedicle  is  charac- 
teristic. Polypi  of  intermittent  presentation  may  remain  un- 
recognized if  the  patient  is  not  observed  at  an  opportune  moment. 
Here  again  artificial  dilatation  is  imposed  as  much  to  complete  the 
diagnosis  as  to  permit  ablation.  An  intravaginal  polypus  from  the 
body  of  the  uterus  could  scarcely  be  confounded  with  a  sessile  or  a 
pedunculated  fibroma  of  the  cervix.  It  might  be  mistaken  for  an 
inverted  uterus,  an  error  which  is  especially  likely  to  occur  if  the 
inverted  organ  itself  contain  a  submucous  fibroid.  Such  an  in- 
version may  remain  unrecognized  in  two  conditions  :  One,  where  it 
is  complicated  by  a  polypus  or  a  submucous  fibroid,  which  alone 
engages  the  attention ;  the  other,  where  there  is  strangulation  of  the 
inverted  organ  at  the  cervix  simulating  a  pedicle.  The  sensitive- 
ness of  the  tumor  termed  by  the  uterus  has  been  noted  as  a 
distinguishing  symptom^  but  it  is  not  of  constant  occurrence.  The 
uterine  sound,  rectal  examination  combined  with  a  sound  in  the 
bladder,  bimanual  palpation  under  anesthesia,  permit  us  to  recog- 
nize that  the  uterus  is  not  in  its  place  in  cases  of  inversion. 

This  examination  will  be  difficult,  however,  with  an  enormous 
polypus  filling  the  vagina,  even  passing  the  ■STilva  and  causing  a 
sort  of  dislocation  of  the  uterus.  These  polypi  may  sometimes 
contract  adhesions  with  the  vaginal  walls  and  cause  ulceration. 
Finally,  by  the  retention  of  decomposed  liquids  in  the  obstructed 
vagina,  they  may  cause  a  continued  putrid  resorption  which  affects 
the  general  health. 

III.  Fibroids  of  abdominal  evolution. — A.  Subperitonceal, 
pedunculated. — The  uterus  is  here  entirely  distinct  from  the  tumor 
and  the  movement  of  the  fibroid  cannot  be  transmitted  to  the  finger 
placed  against  the  cervix  (Fig.  67).  The  uterus  is  generally  lifted 
up.  Ordinarily  there  is  no  haemorrhage  and  the  cavity  may  not  be 
enlarged.  Cysts  of  the  ovary  is  the  condition  most  easily  con- 
founded with  this  variety  of  the  fibromata.  The  fluctuation  of  the 
cyst  is  pathognomonic,  but  this  should  not  be  mistaken  for  the 
softness  of  some  oedematous  fibroids.  Besides,  in  small  and  very 
tense  cysts,  or  mulilocular  with  small  areolar  cavities,  fluctuation 
becomes  difficult  of  appreciation.  Examination  under  anesthesia 
removes  the  doubt.  In  fibro-cystic  tumors  there  are  generally  some 
hard  portions  to  be  found  aside  from  the  fluctuating  points. 
Another  important  consideration  is  that  of  the  slowness  of  develop- 
ment of  a  fibroid  compared  with  the  rapidity  of  that  of  cystic 
tumors.  However,  there  are  some  pedunculated  fibrous  tumors 
which  develop  so  rapidly  and  give  rise  to  so  little  reaction  on  the  side 
of  the  uterus  that  in  every  "  ovariotomy  one  should  be  prepared 
to  perform  hysterectomy."  Exploratory  puncture  should  be  pro- 
scribed.   It  exposes  to  serious  accidents,  effusion  into  the  abdominal 


148  Fibroid  Tumors  of  the  Uterus. 

cavity  in  the  ease  of  cyst,  internal  hfemon-bage,  thi-ombosis  and 
embolism  in  the  case  of  fibroma,  sometimes  a  more  or  less  extended 
peritonitis. 

H.  Jones  has  noted  an  exceptional  condition  of  the  gravid  uterus 
that  may  simulate  a  pedunculated  fibrous  body.  The  uterus  formed 
a  tumor  the  size  of  the  fist — round,  hard,  mobile — situated  between 
the  symphysis  and  the  umbilicus,  and  gave  the  sensation  of  a  mass 
united  to  a  pelvic  organ  by  a  long  pedicle.  Pressure  on  the  tumor 
acted  only  feebly  on  the  cervix ;  no  fluctuation ;  the  uterine  sound, 
passed  before  pregnancy  was  recognized,  gave  about  twelve  centi- 
metres. The  author  attributes  this  special  condition  of  the  gravid 
uterus  to  the  absence  of  amniotic  fluid ;  the  fundus  of  the  uterus, 
as  the  \isual  position  of  the  oxTim,  becomes  then  globular  while  the 
inferior  segment  remains  flaccid,  giving  the  sensation  of  a  pedicle. 
It  is  more  probable  that  this  was  a  beginning  pregnancy,  associated 
with  hypertrophy  of  the  supravaginal  portion  of  the  cervix.  In 
such  a  case  time  would  dispel  all  doubts. 

Floating  kidneys  will  be  recognized  by  their  form  and  the  total 
absence  of  connections  with  the  uterus.  Cancerous  masses  formed 
by  the  degeneration  of  the  great  omentum,  in  cases  of  cancer  of  the 
peritonaeum,  may  be  misleading  if  there  seems  to  be  connection 
with  the  uterus.  But  the  sanguinolent  ascites,  the  form  and  the 
dissemination  of  the  tumors,  the  cachexia,  the  concomitant  phe- 
nomena, the  indemnity  of  the  uterus  revealed  bj^  the  sound  and  by 
bimanual  exploration,  ■will  be  guarantees  against  a  long  hesitation. 

B.  SubjJeritoiKeal  fibroids,  sessile  {not  included  in  the  broad  liga- 
ment).— The  differential  diagnosis  from  other  abdominal  tumors  is 
the  same  as  in  the  preceding  cases.  A  diagnosis  often  very  diffi- 
cult is  that  of  pregnancy  complicating  a  subperitoneal  sessile 
fibroid.  Exact  analysis  of  the  sjTnptoms  and  the  careful  search  for 
those  which  characterize  the  presence  of  a  fcetus  \rill  remain  -nith- 
out  result  only  in  the  first  months.  The  fibromata  of  this  variety 
•\rill  be  distinguished  from  those  that  are  pedunculated  by  the 
solidity  of  their  union  ^vith  the  uterus,  a  symptom  revealed  clearly 
by  bimanual  exploration.  The  tumor  and  the  uterus  appear  to  be 
only  a  single  mass.  At  the  same  time  account  is  taken  of  the  invasion 
of  the  inferior  pari  of  the  uterus ;  intact  when  the  development  is 
above  the  insertion  of  the  appendages,  enlarged  when  the  contrary 
takse  place.  The  mass  is  then  immobilized  in  the  pelvis  and  will 
not  respond  to  movement  from  right  to  left,  but  on  bimanual 
exploration  the  iliac  fosste  are  found  free,  a  feature  wlueh  dis- 
tinguishes this  variety  from  the  following : 

C.  Fibromata  included  in  the  broad  ligament,  or  intra-ligamentous. — 
Abdominal  variety. — Here  the  development  of  the  tumor  has  been 
especially  lateral  in  the  folds  of  the  broad  ligament.  Usually  the 
tumor  de^•iates  into  one  of  the  iliac  fossae  which  it  fills  and  where  it 


Fibroid  Tumors  of  the  Uterus.  149 

is  immobilized.  By  touch  and  by  palpation  its  connections  with 
the  uterus  can  be  more  or  less  easily  determined.  In  many  cases 
it  is  only  one  of  the  lobes  of  the  fibroma  that  is  intra-ligamentous  ; 
one  portion  being  in  the  folds  of  the  ligament,  the  other  being  above 
them.  It  is  only  in  exceptional  cases  that  these  fibromata  give  rise 
to  difficulty  of  diagnosis.  Parovarian  cysts  will  be  recognized  by 
their  fluctuation.  Encysted  tumors  of  the  tubes,  especially  hydro- 
and  hffimato-salpinx  are  often  difficult  of  diagnosis  because  of  the 
adhesion  of  the  tumor  to  the  posterior  surface,  or  to  one  of  the  sides 
of  the  uterus,  and  of  the  difficulty  of  perceiving  fluctuation. 

Pelvic  variety. — The  characteristic  of  this  variety  is  the  develop- 
ment of  the  neoplasm,  so  to  speak,  in  the  tissues  of  the  pelvic  floor 
among  the  organs  attached  there,  with  tendency  to  infiltrate  the 
interstices  which  separate  them,  rather  than  to  become  detached 
from  the  body  of  the  uterus  and  develop  in  the  direction  of  the 
abdominal  cavity  (Fig.  70  B).  From  this  results  the  serious  acci- 
dents of  pressure.  The  origin  of  these  tumors  is  always  in  the 
subserous  portion  of  the  uterus,  that  is  to  say,  in  the  supravaginal 
part  of  the  cervix.  When  they  arise  from  the  anterior  surface,  at 
their  inception,  and  while  they  have  yet  a  medium  volume,  scarcely 
appreciable  to  exploration,  they  may  cause  serious  vesical  dis- 
turbance— dysuria,  retention  of  urine.  This  variety  also  causes 
intense  pains,  from  the  compression  of  nerves,  and  intestinal 
disturbances.  Vaginal  and  rectal  examination,  associated  with 
palpation,  reveal  their  connections  with  the  pelvic  organs.  The 
vaginal  culs-de-sac  are  effaced,  sometimes  depressed,  the  cervix 
itself  may  disappear,  absorbed,  so  to  speak,  by  the  neoplasm.  All 
around  the  os  uteri  are  felt  hard,  mammillated  masses,  dependent  on 
the  uterus,  and  not  displaced  by  pressure.  Tliis  last  symptom  differ- 
entiates the  pelvic  fibroids  from  those  fibroids  that  immigrate  into 
the  pelvis  in  consequence  of  retroflexion  of  the  uterus.  This  last 
variety,  which  may  produce  the  same  accidents  of  compression  and 
give  analogous  sensations  to  touch,  are  not  flexed  (unless  from 
consecutive  adhesions)  in  the  excavation.  By  placing  the  woman  in 
the  genu-pectoral  position  and  exercising  a  pressure  on  the  mass  it 
is  displaced  and  passes  above  the  superior  strait. 

Hsematocele,  nuclei  of  periuterine  inflammations,  encysted  col- 
lections of  the  tubes,  will  be  recognized  by  the  onset  and  progress 
of  the  disease.  Tliis  diagnosis  is  sometimes  difficult  and  has  given 
rise  to  numerous  errors. 

Before  terminating  tliis  clinical  description  I  will  note  some 
symptoms  more  rarely  observed.  There  is  a  symptom  common  to 
all  solid  tumors  that  compress  the  large  abdominal  vessels,  an 
intermittent  souffle,  called  the  uterine  souffle  in  pregnancy.  It  has 
no  diagnostic  value.  If  it  is  wanting  in  ovarian  tumors,  it  is  when 
the  fluctuation  permits  no  doubt.     It  is  met,  on  the  contrary,  in 


150  Fibroid  Tumors  of  the  Uterus. 

solid  tumors  of  the  ovary.  In  telangieetasie  fibroids  there  may  he 
at  the  side  of  the  broad  ligaments  a  distinct  focus  of  a  soft  souffle, 
resembling  that  of  an  arterio-venous  aneuerism. 

Ascites  is  rare  in  fibroid  tumors.  However,  it  may  exist  in  very 
movable  tumors  and  also  in  those  which  undergo  degeneration  from 
torsion  of  their  pedicle.  Finally,  it  may  be  obsened  among 
cachectic  patients.  Haemorrhagic  ascites  is  an  almost  constant 
symptom  of  malign  tumor,  and  its  presence  induces  reservations 
as  to  the  nature  of  the  tumor.  I  have  fi'equently  remarked  the 
coexistence  of  serous  cysts  of  the  broad  ligament  in  the  large 
fibromata  of  abdominal  origin.  The  dragging  do\vnward  of  the 
organ,  which  some  large  uterine  tumors  produce,  may  give  rise  to 
genital  prolapsus.  The  same  fact  is  true  with  regard  to  some 
ovarian  tumors.  Inversion  of  the  uterus  may  be  produced  by 
polypi  or  by  subserous  fibroids,  exceptionally.  A  very  rare  acci- 
dent is  the  separation  of  the  linea  alba  and  eventration  pushed  to 
the  point  of  permitting  the  formation  of  a  hei-nial  sac  in  which  the 
fibrous  tumor,  generally  pedunculated,  is  found. 

Progress  and  Prognosis. — A  vast  majority  of  fibroid  tumors  give 
rise  only  to  some  vague  and  often  unrecognized  phenomena.  Even 
though  they  may  have  caused  serious  troubles  during  the  period  of 
sexual  activity,  the  majority  have  a  natural  tendency  to  atrophy,  or 
at  least  to  diminish  in  volume  by  a  species  of  involution  and  indu- 
ration, at  the  menopause.  This  is  sometimes  hastened  by  the 
remote  effect  of  a  pregnancy.  This  rule,  however,  is  not  absolute. 
On  the  other  hand  there  are  many  tumors  that  make  rapid  progi-ess, 
causing  the  death  of  the  patient,  not  so  much  by  hiemorrhage  as 
by  the  excessive  development  of  the  morbid  mass  and  the  phe- 
nomena of  compression  and  denutrition  which  result.  To  this 
number  belong  the  generality  of  the  fibro-cystic  tumors  and  also 
some  simple  fibro-myomata.  Some  other  tumors  of  less  rapid 
progi'ess  continue  to  grow  indefinitely  after  the  critical  age,  and 
the  climacteric  is  then  sometimes  notably  delayed. 

It  may  be  said  that  the  natural  evolution  of  fibromata  tends  to 
cause  their  expulsion  from  the  walls  of  the  uterus,  either  toward 
the  exterior  or  toward  the  peritonseal  cavity.  This  effort  is  shown 
by  the  ]3edunculation  in  these  two  dii-ections.  This  end  is  reaUy 
attained  sometimes,  although  the  great  majority  of  cases  are 
exceptions  to  this  rule.  However,  the  delivery  of  a  polypus  has  been 
observed  often  after  rupture  of  the  pedicle  under  the  influence  of 
strong  contractions  of  the  uterus,  or  even  by  the  effect  of  weight  and 
the  thinning  of  its  attachments.  An  effort  of  defecation  or  of  vomit- 
ing is  sufficient  then  to  cause  expulsion  of  the  poh^pus.  The  rapture 
of  the  capsule  of  a  submucous  fibroid  may  be  accomphshed  in 
analogous  conditions  and  give  rise  to  spontaneous  enucleation.  It 
is  sometimes  preceded  by  pains  and  haemorrhages,  other  times  it  is 


Fibroid  Tumors  of  the  Uterus.  151 

made  suddenly  during  an  effort  or  even  an  exploration.  Analogous 
processes  may  also  liberate  a  subserous  pedunculated  fibroid.  The 
tumor  then  remains  grafted  to  a  part  where  it  has  contracted 
adhesions  or  it  eveii  remains  free  in  the  peritonseum  and  undergoes 
a  sort  of  mortifieation. 

Another  much  more  grave  mode  of  spontaneous  expulsion  is 
produced  by  gangrene  of  the  fibroid.  The  sphacelating  tumor  tends 
to  make  its  way  toAvard  the  exterior.  Sometimes  it  is  eliminated 
toward  the  uterine  cavity  and  may  pass  away  without  injury  in  spite 
of  the  dangers  of  septic  infection.  Sometimes  it  perforates  a 
contiguous  organ,  the  bladder,  Douglas'  cul-de-sac,  or  even  the 
abdominal  wall.  The  first  two  ways  almost  always  cause  death,  the 
last  terminates  in  cure. 

Fibromata  are  certainly  a  cause  of  sterility ;  however,  pregnancy 
may  take  place  and  e^'en  follow  a  natural  course. 

Fatal  termination  may  be  caused  by  the  ansmia  produced  by  the 
repeated  hasmorrhage,  by  the  successive  exacerbations  of  chronic 
peritonitis,  by  the  disease  of  the  kidneys  and  the  urtemia,  by  the 
cardiac  affection.  It  may  also  follow  rapidly  from  acute  peritonitis 
due  to  the  rupture  of  a  cyst  or  caused  by  the  gangrene  and  the 
inflammation  of  the  tumor,  propagated  with  or  without  perforation 
to  the  neighboring  serous  membrane.  A  fatal  septicaemia  may  arise 
from  the  gangrene  of  a  submucous  fibroid.  Finally,  sudden  death 
has  been  observed  in  consequence  of  embolism,  and  it  is  especially 
in  the  fibro-cystic  tumors  with  telangiectasis  that  tliis  termination 
is  to  be  feared.  It  should  be  noted  that  exploratory  punctures  seem 
to  favor  and  excite  thromboses  in  the  large  venous  sinuses.  Almost 
immediate  death  has  also  been  observed  from  shock  in  consequence 
of  the  intraabdominal  rupture  of  fibro-cystic  tumors. 

Etiology. — In  spite  of  the  patient  researches  that  have  been  made 
on  this  subject  we  know  nothing  positive  on  the  exciting  causes  of 
fibromata.  We  may,  however,  give  some  hints  as  to  the  predisposing 
causes. 

The  negro  race  is  more  subject  than  the  white  race,  and  at  a  less 
advanced  age.  It  is  at  from  thirty  to  forty  years,  in  our  race,  that 
we  especially  observe  their  development.  Sterility  is  not  a  cause 
but  a  consequence.  All  the  exciting  local  causes  have  been  invoked 
without  proof.  On  the  other  hand  it  has  been  held  that  celibacy 
favors  the  development  of  fibroids.  Gusserow's  statistics  have  dis- 
proved this.  FeMing  attributes  great  importance  to  incomplete 
involution  of  the  uterus  after  accouchement  or  miscarriage  when 
the  woman  is  allowed  to  get  up  too  soon. 


152  Treatment  of  Fibroid  Tumors. 


CHAPTER  X. 


MEDICAL  TREATMENT   OF   FIBROID   TUMORS.— 

SURGICAL    TREATMENT    OF    FIBROID 

TUMORS  OF  VAGINAL  EVOLUTION. 

The  treatment  of  fibroid  tumors  may  be  divided  into  the  medical 
and  the  sm-gical.  Most  often  the  medical  treatment  is  only  symp- 
tomatic. The  various  drugs  which  have  been  advised  with  the  view 
of  acting  directly  on  the  tumor,  either  to  constrict  the  nutritive 
vessels  (ergot) ;  or  to  obtain  a  fatty  degeneration  (arsenic,  phos- 
phorus), appear  in  reality  to  act  on  a  different  principle.  The  first, 
by  causing  contraction  of  the  uterine  fibers  and  thus  moderating 
the  hemorrhages ;  the  second  (at  least  arsenic),  by  improving  the 
general  nutrition  of  the  patient.  There  remain,  as  specific  agents, 
electricity,  to  which  certain  authors  attribute  considerable  influence 
in  the  resorption  of  fibrous  tumors,  and  the  sodium-chloride  mineral 
waters,  the  action  of  which  appears  incontestable  in  this  dii-ection. 

Ergot  has  been  employed  methodically  in  hjTpodermic  injections. 
It  must  be  used  ^\ith  persistence,  during  some  months.  The  follow- 
ing solution  may  be  used : 

B    Ergotine,  5  grammes ; 

Hydrate  of  chloral,  I  gramme ; 
Distilled  water,  100  grammes. 

Inject  twelve  drops  a  day,  making  about  twenty-five  centi- 
gi-ammes.  If  the  solution  is  to  be  kept  long,  there  should  be  added 
besides  the  chloral,  which  is  designed  only  to  preserve  it,  some 
drops  of  von  S^^■ieten's  solution.  The  injection  should  be  made  in 
a  fleshy  part  and  the  needle  pushed  m  perpendicularly  two  to  thi-ee 
centimetres.  In  spite  of  the  gi-eat  number  of  so-caUed  demon- 
strations that  have  been  published,  the  effect  of  this  method  on  the 
development  of  filiroid  tumors  is  stiU  contested.  By  employing  the 
drug  according  to  the  method  mdicated,  there  should  be  no  acci- 
dents. If  this  dose  is  exceeded  by  very  much,  there  may  follow 
cramps  in  the  extremities,  vomiting  and  fever.  Even  suppuration 
of  the  tumor  and  aphasia  have  been  noted.  One  of  the  effects  that 
have  been  attributed  to  tliis  treatment  is  that  it  favors  the  spon- 
taneous expulsion  of  the  filiroids.  But  it  is  very  doubtful  if  it  is 
sufficient  to  provoke  pedunculation  of  sul)mucous  fibroids,  and  with 
regard  to  those  that  have  already  become  polypi  they  call  for  treat- 
ment other  than  medical. 

Churchliill  and  MacClintock  praise  tiie  tincture  of  cannabis  indica, 


Treatment  of  Fibroid  Tmnors.  153 

in  six-drop  doses,  three  times  a  day,  for  the  arrest  of  haemorrhage. 
Antipyrine  has  also  been  tried  for  the  same  purpose.  The  fluid 
extract  of  hydrastis  canadensis  appears  to  act  by  contracting  the 
vessels,  as  a  haemostatic.  The  dose  is  tweuty-five  drops,  two  or 
three  times  a  day.  The  bromide  of  potassium  has  been  recom- 
mended by  Simpson,  in  small  doses  long  continued.  It  appears  to 
act  only  as  a  sedative  and  its  prolonged  use  alters  the  digestive 
functions.  On  the  contrary,  arsenic,  if  it  has  not  the  elective  action 
hoped  for,  has  at  least  a  reconstructive  action  which  may  be  very 
useful.  The  sodiu,m-chloride  mineral  waters  have  an  undeniable 
action  on  fibroid  tumors.  They  also  act  on  the  general  nutrition. 
The  cases  in  which  I  have  obtained  a  marked  amelioration  by  their 
use  are  very  numerous. 

Electricity  has  lately  been  in  vogue,  particularly  fi-om  the  empha- 
sis which  has  been  given  to  its  use  by  Apostoli.  It  is  known  that 
currents  of  some  intensity  produce  a  chemical  decomposition  of  the 
tissues.  At  the  positive  electrode  the  acid  elements  are  liberated,  at 
the  negative,  the  basic  elements.  If  then  the  positive  pole  (acid)  is 
placed  in  contact  with  the  tissues,  either  the  surface  of  a  mucous 
membrane,  or  in  the  depths  of  a  tumor,  there  is  produced  an  eschar, 
which,  like  those  that  succeed  to  acids,  ends  in  a  fibrous,  retractile 
cicatrix.  If  the  contact  takes  place  with  the  negative  pole  (basic) 
the  eschar  produced  wiU  be  like  that  from  the  action  of  caustic 
potash,  soft  and  non-retractile.  Chemical  action,  at  one  of  the 
poles,  can  be  avoided  using  moist  clay,  gelosine,  gelatine,  etc.,  or  by 
the  use  of  large  metallic  plates  covered  with  cotton  or  chamois  skin, 
to  distribute  the  action  over  a  large  surface.  Mariy  advocates  of 
electricity  employ  weak  currents  having  a  catalytic  action  without 
true  destruction  of  the  tissues.  But  the  great  majority,  following 
the  example  of  Apostoli  and  of  Engelmann  (St.  Louis),  use  currents 
of  high  intensity.  In  1884  Apostoli  did  not  exceed  one  hundred 
milhamperes,  now  he  often  uses  two  hundred  and  fifty. 

Apostoli's  technique  is  as  follows  :  One  of  the  poles  being  appHed 
on  the  abdomen,  by  the  mtervention  of  a  cake  of  clay  or  other 
appropriate  means,  the  other  electrode  in  the  form  of  a  platinum 
sound,  isolated  in  all  its  length  by  celluloid  or  rubber  except  the 
uterine  part,  is  pushed  into  the  uterine  cavity,  or  even  into  the 
parenchyma  itself,  through  "a  previous  puncture,  which  will  be 
obUgatory  when  the  cervix  is  inaccessible  or  impermeable,  or,  that 
is  a  method  of  choice  when  it  is  mshed  to  accelerate  the  denutrition 
of  the  neoplasm  more  rapidly."  Thus  is  produced  an  intrauterine 
eschar,  by  using  the  positive  pole  if  there  is  a  haBmorrhagic  fibroma, 
and  the  negative  in  other  cases.  Apostoli  affirms  that,  "well 
applied  and  sufficiently  continued  (from  three  to  nine  months  on  the 
average)  this  method  in  the  majority  of  cases  is  successful  and 
leads  ninety-five  times  out  of  one  hundred  to  the  following  results : 


154  Treatment  of  Fibroid  Tumors. 

Anatomical  regi-ession  of  the  fibroma,  varying  from  one-fifth  to  one 
third  and  sometimes  even  one-half,  but  never  total  disappearance  ; 
rapid  and  durable  arrest  of  the  haemorrhages,  and  disappearance  (^f 
the  phenomena  of  compression."  Eugelmann  describes  a  similar 
method.  He  has  also  practiced  exceptionally  double  punctui'e  of 
the  tumor  through  the  vagina.  He  employs  an  intensity  of  from 
fifty  to  two  hundred  and  fifty  milliamperes,  dming  thi-ee  to  eight 
minutes. 

What  is  the  mode  of  action  of  this  method  ?  It  appears  that  its 
partisans  recognize  a  double  action :  Fii'st,  the  cauterization  of  the 
mucosa,  producing,  as  Apostoli  terms  it,  a  veritable  electrical 
curetting.  Now  we  know  that  ciu-etting  is  often  efficacious  against 
the  hasmorrhage  produced  by  fibroids  by  ehminating  the  altered 
mucosa.  Curetting  aud  consequently  electricity  may  without  doubt 
thus  cause  superficial  mortification  of  the  submucous  fibroids. 
However,  this  destruction  can  never  be  anytliuig  but  incomjjlete, 
linear,  corresponding  to  the  reetOinear  path  of  the  sound  in  the  uterus. 
It  should  not  be  compared  to  that  obtained  by  the  curette,  which 
scrapes  all  the  surface  and  reaches  into  all  the  angles.  Then  another 
mode  of  action  is  invoked  bj^  the  partisans  of  electro-therapy,  that 
is  what  they  caU  the  iuterpolar  action.  Unhappily  its  signification 
is  badly  defined  and  stiU  hypothetical.  Does  it  mean  a  chemical 
modification  of  the  media  in  which  the  constituent  elements  of  "the 
tumor  reside  ?  Is  it  an  electro-tonic  action  on  the  muscular  fibre, 
a  vaso-motor  action,  or  both  at  once  ?  Danion  has  gone  so  far  as 
to  speak  of  a  galvanic  massage  of  the  tumor,  carrying  out  this  idea 
by  reversing  the  current.  It  is  necessary  to  avow  that  all  these 
explanations  are  very  hypothetical  and  represent  only  imaginary 
views.  This  method  is  not  without  danger.  Two  deaths  have  been 
cited  in  France. 

Cutters  method  is  much  more  dangerous.  He  uses  elements  of 
large  sm-face  aud  puuctm-es  the  tumor  at  two  points,  either  thi'ough 
the  vaguia,  thi'ough  the  rectiim,  or  tlnough  the  abdominal  walls. 
Out  of  fifty  cases  he  has  had  at  least  four  deaths.  The  results 
obtained  were  as  follows :  fibroids  not  aiTested  in  their  progi'ess, 
seven  cases  :  arrest  of  progi-ess,  twenty-five  :  reheved,  three ;  cured, 
eleven. 

Eeacting  against  the  violent  procedures  Danion  and  Champion- 
niere  advise  feeble  intensities,  usually  from  forty-five  to  sixty-five 
milliamperes,  or  more,  very  rarely  they  go  as  high  as  ninety.  These 
medium  currents  are  as  satisfactory  as  the  intense  cuiTents.  Danion 
attaches  especially  gi-eat  importance  to  frequent  reversals  of  the 
current.  He  introduces  the  electrode  into  the  cervix  only,  and  even 
claims  that  the  same  phenomena  can  be  obtained  with  an  intra- 
vaginal  pule  if  the  necessary  precautions  are  taken.    This  would  be 


Treatment  of  Fibroid  Tumors.  155 

important,  for  it  is  sometimef?  impossible  to  reach  the  cervix  and 
especially  to  enter  it. 

It  is  very  difficult,  even  to-day,  to  formulate  an  opinion  of  the 
value  of  electricity  in  fibroids.  One  can  scarcely  form  an  opinion 
on  the  contradictory  testimony  presented.  Gynscologists  seem 
divided  into  tvi^o  camps  in  America,  England  and  Germany.  In' 
France  there  are  three  opinions.  Doleris,  after  employing  this  treat- 
ment in  twenty  cases,  believes  that  the  results  are  often  deceptive, 
that  what  appears  to  be  a  diminution  is  only  a  prolapsus  of  the 
tumor  bodily  into  the  pelvic  cavity.  Care  should  be  taken  not  to 
consider  perimetritic  exudations  as  fibrous  tumors,  as  these  are 
subject  to  resorption  by  rest  and  co-operative  measures.  From  an 
important  discussion  at  the  Societe  de  Chirugie,  it  appears  also  that  the 
value  of  this  therapeutical  agent  has  been  exaggerated  so  far  as 
regards  diminution  of  volume  of  the  tumors.  When  this  is  accom- 
plished, it  is  never  more  than  transient  and  ceases  with  the  discon- 
tinuance of  the  galvanic  treatment.  But  the  majority  of  observers 
admit  that  it  markedly  diminishes  the  hemorrhages  and  the  pains. 
Without  falling  into  the  exaggerations  of  Thomas  Keith,  who  declares 
it  criminal  to  perform  hysterectomy  without  having  first  tried  elec- 
tricity, it  is  necessary  to  remember  that  it  is  a  therapeutic  resource 
wliich  should  not  be  neglected  in  cases  where  operative  interference 
does  not  appear  to  offer  chances  for  a  radical  cure.  I  merely  men- 
tion the  action  of  interrupted  currents,  their  use  is  not  generally 
advised.     The  same  is  true  of  Faradization. 

Treatment  of  the  symptoms  of  com}wession. — Some  fibrous  tumors, 
either  arising  in  the  pelvic  cavity  or  retroflexed  into  the  cavity,  may 
occasion  accidents  of  compression  of  the  rectum,  of  the  bladder,  or 
of  the  nerves.  Sometimes  these  symptoms  can  be  relieved  by 
pusliing  the  tumors  above  the  promontory.  The  patient  is  placed 
in  Sim's  position,  or  better  in  the  genu -pectoral,  and  the  tumor  is 
pushed  up  either  by  the  finger  in  the  rectum  or  in  the  vagina.  If 
there  is  much  hypereesthesia  aiid  muscular  contraction  cMoroform 
will  be  used.  This  procedure  has  also  rendered  service,  during 
delivery,  in  cases  of  fibroids  complicating  pregnancy. 

Minor  hemostatic  operations. — Before  touching  upon  the  major 
operations  that  we  may  be  called  to  perform  in  fibromata  of  the 
uterus,  I  will  speak  of  some  procedures  directed  against  haemor- 
rhages ;  operations  which,  by  their  simplicity,  rank  between  medical 
and  surgical  treatment  proper. 

Curetting  and  intrauterine  injections. — These  procedures  have  often 
been  employed,  without  doubt  in  consequence  of  a  diagnostic  error 
and  in  beHef  of  the  existence  of  a  hsemorrhagic  metritis.  Eecent 
researches  on  the  state  of  the  mucosa  in  cases  of  fibroids  show,  how- 
everj  that  there  is  something  rational  in  their  effects.     They  may 


156  Treatment  of  Fibroid  Tumors. 

succeed  -nheu  the  uterine  cavity  is  not  too  much  deformed.  The 
injection  of  perchloride  of  iron  should  l)e  followed  by  profuse  douching 
with  the  double -current  cauula,  and  both  these  procedures  should  lie 
made  with  gi-eat  care  because  the  tubes  are  often  notably  dilated 
and  permeable  in  these  cases. 

Dilatatknt  of  the  cerri,r.  —  Kaltenbach  employs  Hegar's  dilators, 
carrying  the  dilatation  as  far  as  sixteen  to  eighteen  millimetres.  In 
thi-ee  cases  he  obtained  remarkable  success.  Kaltenbach  is  led  to 
attribute  a  great  influence  to  the  naiTowiiess  of  the  cervical  canal  in 
the  production  of  pains  and  haemorrhages  dependhig  upon  myomata . 
He  especially  recommends  this  as  a  palliative  in  cases  of  medium- 
sized  tumors  in  women  approacliing  the  menopause,  that  is  to  gain 
time.     I  have  used  it  once  with  marked  success. 

Bilateral  section  of  the  cervix.  —  This  operation  only  acts  if  the 
incision  is  pushed  sufficiently  far  to  cut  and  hgate  the  important 
branches  of  the  uterine  artery.  It  is  reduced  then  to  hgature  of 
these  vessels.  It  is  of  utihty  only  in  the  very  exceptional  cases 
where  the  neoplasm  occupies  the  inferior  segment  of  the  uterus. 

Intrauterine  scarification.  —  In  cases  of  obstinate  hiiemoiThage 
depending  upon  an  intrauterine  fibroma.  Mai-tin  uses  the  old  method 
introduced  by  Simpson,  the  incision  of  the  capsule  by  a  scarification 
of  the  projecting  part  of  the  submucous  tumor.  The  di\-ided  vessels 
retract. 

Surgical  treatment  of  fibroid  tumors.  —  The  operations 
that  may  Ije  appUed  to  fibromata  differ  according  as  the  tumors 
are  accessible  thi'ough  the  natural  passages  or  only  through  the 
abdomen.  The  progi'ess  of  operative  g>"nfecology  makes  it  possible 
to-day  to  avoid  for  the  most  part  abdominal  section.  I  will  discuss, 
in  this  chapter,  only  the  fibrous  tumors  that  are  pushed  toward 
the  vagina  by  theii-  evolution  and  that  are  accessible  through  this 
passage. 

A.  Fibrous  tumors  of  the  vaginal  portion  of  the  cervi.i. — About  the 
cervix,  from  the  thinness  of  the  tissues,  there  is  no  chance  to  dis- 
tiaguish  fibroids  as  submucous  and  interstitial.  They  are  usually 
easily  detached  from  the  contiguous  tissue.  An  attempt  may  be 
made  to  eniicleate  them  ^vith  the  finger  and  a  spatula,  after  having 
removed  then-  inferior  portion  and  having  sufficiently  diminished 
their  size  by  ablation  of  a  pari  or  by  a  conoidal  section,  so  as  to 
facilitate  the  procedure.  It  is  quite  useless  to  complicate  the  oper- 
ation by  using  for  the  morccllement  the  ecraseur  or  the  galvano- 
cautery  loop.  The  last  is  dangerous  to  the  neighboring  parts  and 
requires  deUeate  management.  '  It  should  only  be  employed  in  very 
exceptional  cases.  The  ecrasem-  that  so  many  sui-geons  still  advise 
is  open  to  many  objections,  some  of  them  very  gi-ave.  It  breaks 
easily  on  tissues  of  extreme  resistance,  it  cuts  very  slowly  and  causes 
the  loss  of  considerable  time,  during  wliich  the  uterus  may  bleed 


Treatment  of  Fibroid  Tumors.  157 

above  the  tumor,  and  finally  it  has  a  tendency  to  creep  up  the  tissues, 
so  that  it  has  sometimes  caused  an  opening  into  the  peritonaeum. 
To  lose  as  little  blood  as  possible  I  believe  that  the  best  method  is 
to  proceed  quickly  with  the  knife.  In  fact,  fibroids  are  but  slightly 
vascular,  and  if  some  vessels  are  divided,  it  is  easy  to  arrest  haemor- 
rhage by  placing  forceps  on  them,  or  by  using  the  thermo-cautery. 
If  the  tumor  of  the  cervix  is  prolonged  upward  toward  the  uterus,  it 
should  not  be  followed  too  far,  only  the  parts  easily  accessible  should 
be  removed,  leaving  the  base  in  place,  as  it  will,  without  doubt,  be 
pushed  outward  later  by  the  uterine  contractions  and  can  then  be 
extirpated.  If  there  is  a  myoma  not  enclosed  in  a  capsule,  ampu- 
tation of  the  tumor  is  made  as  high  as  possible,  preserving  two  flaps 
which  are  reunited.  When  there  is  a  clean  wound  after  enucleation 
its  edges  can  also  be  pared  and  sutui'ed.  But  if  primary  union  is 
deemed  impossible  the  debris  is  dissected  from  the  capsule  and  the 
wound  dressed  with  iodoform  gauze. 

B.  Pedunculated  fibroids  {of  the  body)  or  polypi. — When  the  polypus 
is  intrauterine  a  preliminary  operation  is  necessary  to  render  it 
accessible.  Bilateral  incision  of  the  cervix  is  preferable.  This  is 
made  with  strong  scissors  as  far  as  the  vaginal  insertion.  The 
supravaginal  portion  of  the  cervix  is  generally  dilated  by  the  efforts 
of  the  polypus  itself.  If  not,  softening  is  induced  with  a  laminaria 
tent  and  the  dilatation  finished  with  Hegar's  dilators.  Then,  if 
necessary,  the  bilateral  incision  is  made.  The  ablation  of  a  polypus 
is  usually  very  simple.  The  patient  is  placed  in  the  dorsal  position ; 
the  vagina  is  held  open  with  retractors ;  the  polypus  is  seized  with 
the  forceps  and  drawn  down  as  much  as  possible,  while  the  hand 
above  the  pubes  makes  sure  that  the  uterus  is  not  inverted.  The 
polypus  is  then  given  a  movement  of  rotation  on  its  axis,  in  such  a 
way  as  to  twist  the  pedicle.  After  two  or  three  turns  a  pair  of  strong 
scissors  curved  on  the  flat  glides  over  the  tumor  to  the  insertion  of 
the  pedicle  and  the  incision  is  commenced  by  making  slight  snips, 
meanwhile  continuing  the  torsion.  This  has  a  double  effect,  it  aids 
the  detachment  of  the  pedicle  and  it  favors  hsemostasis.  It  is  gen- 
erally advised  to  cut  the  pedicle  as  high  as  possible.  By  the  opposite 
course,  one  is  put,  I  believe,  more  on  guard  against  the  chances 
(very  problematic)  of  secondary  htemorrhage.  The  cut  pedicle 
retracts  into  the  uterine  cavity  and  the  portion  which  remains 
shi'ivels  and  is  rapidly  obliterated  in  consequence  of  the  torsion  it 
has  undergone. 

All  the  means  employed  for  fear  of  haemorrhage  should  be 
abandoned.  They  have  caused  more  victims  than  they  have  saved 
patients.  The  galvano-cautery  loop,  the  serre-noeud,  the  eeraseur, 
the  ligature,  all  prolong  and  infinitely  complicate  an  operation, 
which  should  be  rapid  to  remain  benign.  In  those  very  rare  cases 
where  the  pedicle  contains  large  vessels,  the  danger  of  haemorrhage 


158  Treatment  of  Fibroid  Tumors. 

may  be  recognized  by  previous  palpation,  and  may  I^e  avoided  by 
placing  on  the  pedicle,  before  cutting  it,  long  i^ressure-forceps-  that 
are  to  be  left  some  hours.  If  haemorrhage  ensues,  injections  of  hot 
water,  ergot,  and,  if  necessary,  antiseptic  tamponade  of  the  uterine 
cavity  mth  iodoform  gauze  Avill  overcome  it. 

I  have  proposed  to  call  enormous  jiolypi  those,  which  Ijy  tiUing  the 
cavities  of  the  vagina,  do  not  allow  the  finger  to  reach  the  pedicle 
and  usually  not  even  to  pass  the  vulva  except  after  certain 
manoeuvers.  The  enormous  polypi  i)resent  special  operative  indi- 
cations. Section  of  the  pedicle  camiot  be  essayed  without  a  previous 
dimininution  of  their  volume.  This  result  is  very  simply  attained 
by  combining  the  different  means  which  have  been  praised  by  turns. 
That  wliich  is  called  operative  elongation  is  obtained  by  deep 
incisions,  made  hke  steps  in  the  tumor,  wliile  it  is  being  drawTi  out- 
ward. The  same  end  is  attained  by  spiral  incisions  in  the  capsule 
of  the  tumor  wliich  is  the  most  resisting  part.  Finally,  morcellement 
by  the  ablation  of  sections  or  of  conoidal  fi-agments,  which  scoop 
out  the  tumor,  appears  to  be  the  best  means.  It  is  better  to  attack 
the  tumor  than  to  incise  the  fourchette  as  has  been  advised.  As 
soon  as  the  tumor  is  sufficiently  diminished  it  is  seized  in  the  large 
forceps.  Compression  reduces  its  volume  still  more,  and  section  of 
the  pedicle  can  be  made  by  the  scissors  at  the  same  time  that  it  is 
being  twisted.  It  is  especially  in  cases  of  women  who  are  enfeebled 
and  cachectic  to  a  high  degree,  that  it  is  necessary  to  employ  these 
expedients  and  not  to  prolong  the  anaesthesia  and  the  operation. 
After  ablation  of  the  polypi  it  is  well  to  do  at  once,  or  at  the  end  of 
some  hours,  a  curetting  followed  by  cauterization,  to  cure  the 
metritis,  which  is  constant,  and  to  cause  a  more  rapid  involution  of 
the  uterus. 

Suhmitcous  fibroids. — It  should  be  understood  that,  clinicaUy,  we 
include  under  this  name  fibroids  which,  although  separated  from 
the  mucosa  by  a  muscular  layer,  are  much  nearer  than  to  the  peri- 
tonseal  surface,  and  that  cause  a  notable  projection  into  the  uterine 
cavity.  At  certain  times,  duiing  the  menses  or  metrorrhagias 
accompanied  by  colic,  the  cervix  may  be  more  or  less  effaced  and 
open  so  as  to  allow  the  finger  to  penetrate  as  far  as  the  projection  of 
the  tumor.  Artificial  dilatation,  in  default  of  the  natural,  permits 
us  to  appreciate  these  anatomical  conditions.  A  pressing  indication 
for  active  interference  is  the  onset  of  gangrene.  The  laxity  of  the 
connections  between  the  uterus  and  the  tumor  contained  in  its  walls, 
the  many  examples  of  spontaneous  expulsion  by  the  simple  efforts 
of  nature,  directs  the  surgeon's  attention  to  their  enucleation. 

According  to  Schroeder,  the  volume  of  tumors  justifying  emicle- 
ation  may  reach  that  of  a  fcetal  head  at  term.  This  operation  wiU 
be  attempted,  he  says,  only  in  the  case  where  the  neoplasm  has 
already  descended  in  greater  part  into  the  vagina.     We  shall  see. 


Treatment  of  Fibroid  Tumors. 


159 


however,  that  segmentation  of  the  tumors  permits  a  much  greater 
extension  of  the  limits  for  operations  through  the  vagina.  Besides, 
it  is  not  alone  when  there  are  very  small  fibroids  that  one  can 
proceed  to  operate  by  enucleation  without  segmentation.  The 
narrowness  and  the  rigidity  of  the  vagina  are  a  sufficient  contra- 
indication in  some  cases.  Attempts  may  be  made  to  overcome  tliis' 
by  the  previous  application  of  tampons.  In  the  absence  of  sponta- 
neous dilatation,  a  passage  may  be  made  with  laminaria  tents  and 
Hegar's  dilators  before  bilateral  incision  of  the  cervix. 
Chobak  prefers  multiple  radiating  incisions  that  are 
sutured  carefully  after  the  operation.  If  the  tumor 
exceeds  the  size  of  the  fist,  enucleation  of  the  tumor  in 
totality  should  not  be  attempted,  preference  then  being 
given  to  segmentation. 

The  operation  varies  considerably  according  to  the 
volume,  the  consistency  and  the  connections  of  the 
fibroid.  Before  giving  the  rules  for  the  operative 
technique,  I  will  remark,  once  more,  that  we  rarely 
make  an  enucleation  as  of  old,  since  a  greater  bold- 
ness has  rendered  segmentation  famOiar  to  the  ma- 
jority of  surgeons.  The  most  convenient  position 
appears  to  be  the  dorso-sacral,  though  some  operators 
prefer  Sims'.  Anaesthesia  is  necessary.  Two  assist- 
ants support  the  patient's  limbs ;  one  depresses  the 
uterus  by  pressing  above  the  pubes,  the  other  attends 
to  the  continued  irrigation,  both  hold  the  retractors. 
It  is  useful  to  have  extra  assistants  as  this  work  is  very 
fatiguing.  When  the  cervix  is  not  sufficiently  dilated 
we  do  not  hesitate  to  incise  it  up  to  the  vaginal  in- 
sertion after  having  made  the  precautionary  hgature  of 
the  inferior  branches  of  the  uterine  artery.  This  is 
the  prehminary  stage.  If  the  tumor  is  small  and  if 
the  cervix  is  not  too  much  thinned  afixation  forceps 
on  one  lip  will  be  of  great  service  in  drawing  down  the 
uterus  and  giving  a  point  of  support  for  the  manceuvres 
of  enucleation. 

The  first  stage  consists  in  opening  the  capsule.  The 
most  projecting  part  of  the  tumor  is  seized  with  the 
polypus  forceps,  and  at  the  point  where  the  mucosa  is 
reflected  from  the  growth  to  the  uterus  an  incision  is 
made  with  the  knife  or  scissors  to  the  greatest  possible 
extent,  if  it  cannot  be  torn  with  the  nails. 

In  the  second  stage  the  tumor  is  peeled  out  with  the  fingers 
introduced  into  the  capsule.  A  spatula  is  necessary  in  some  eases. 
It  should  be  blunt  and  slightly  concave.  I  have  designed  an  enucle- 
ator  which  has  done  me  great  service  (Fig.  74) .     I  prefer  it  to  Sims 


Fig.  74. 

Pozzi's  Enuc- 

leator. 


160  Treatment  oj  Fibroid  Tumora. 

enucleator  and  to  Thomas'  serrated  scoop.  In  proportion  as  the 
adhesions  of  the  fibroid  have  been  destroyed  to  a  certain  extent,  it 
is  drawii  doNMiward  bj-  taldug  a  new  grasp  with  the  polypus  forceps. 
The  fibroid  is  thus  made  to  roll  on  its  axis,  if  nec-essary  cutting  \\ith 
the  scissors  the  fibrous  bands  that  do  not  yield  to  the  enucleator. 

The  third  stage,  or  the  delivery  of  the  tumor,  is  troublesome  onlj' 
if  it  is  voluminous  ;  then  segmentation  and  reduction  with  the  small 
forceps  may  be  necessary,  as  in  enormous  polypi.  I  was  able  to 
deliver  in  a  mass,  mth  the  ovum  forceps,  an  intrauterine  fibroid 
larger  than  the  fist,  that  I  enucleated,  not  from  its  capsule,  but 
from  the  uterine  canity  where  it  had  contracted  adhesions.  This 
was  a  very  curious  case  of  a  polypus  with  intermittent  presentation. 
Various  instmments  hate  been  constructed  for  the  extraction  of 
voluminous  tumors,  but  the  armamentarium  can  be  reduced  to  the 
instmments  I  have  indicated. 

When  fatigue  on  the  part  of  the  operator  or  the  exhaustion  of  the 
patient  have  suspended  the  operation  before  completing  the  extir- 
pation, there  is  sometimes  seen  either  spontaneous  elimination  of 
the  rest  of  the  tumor  at  the  end  of  some  days,  or,  at  a  second 
operation,  few^er  difficulties  in  consequence  of  infiltration  of  the 
capsule  and  relaxation  of  the  adhesions.  This  last  fact  gave  to 
some  operators  the  idea  of  making  the  operation  in  several  stages. 
But  this  is  transforming  a  condition  of  necessity  into  one  of  choice. 
It  exposes  the  patient,  in  fact,  to  the  dangers  of  septicaemia  which 
has  followed  in  cases  treated  in  this  manner.  There  is  another 
operation  in  two  stages :  in  place  of  making  two  sittings  for  the 
enucleation  there  is  only  made  in  the  first,  after  the  method  of  Atlee, 
a  deep  incision  in  the  capsule.  Several  days  later,  when  it  is 
supposed  that  the  uterine  contractions  have  produced  the  dehiscence 
of  the  incision  and  a  certain  detachment  of  the  tumor,  enucleation 
is  proceeded  with.  Vulliet  has  recently  taken  up  Atlee's  method 
and  perfected  it.  He  fii'st  tries,  somewhat  theoretically,  to  direct 
the  fibroid  from  its  very  first  appearance  toward  the  uterine  ca\ity, 
rather  than  toward  the  abdominal  cavity,  by  the  use  of  electricity 
(galvanic  current).  Then,  the  fibroid  having  become  submucous  is 
treated  by  incision  of  its  capsule ;  finally,  ergotuie  and  electricity 
will  give  to  the  tumor  a  tendency  to  spontaneous  enucleation.  This 
is  still  more  accentuated  by  the  intrauterine  tamponnement  with 
iodoform  gauze  renewed  evei-y  forty-eight  hours.  Finally,  operative 
interference  terminates  the  work  of  si^ontaneous  expulsion,  which 
sometimes  takes  place  in  the  form  of  a  polypus,  sometimes  in 
sections.  This  method  may  be  reproached  with  extreme  slowness, 
the  multiplicity  of  manoeuvres  to  which  the  uterus  is  exposed  and 
useless  temporizing  when  the  tumor  has  become  accessible  to 
operation. 

Tf  it  is  impossible  to  remove  the  whole  of  the  tumor,  except  by 


Treatment  of  Fibroid  Tumors.  161 

the  use  of  dangerous  force,  we  are  resigned  to  leaving  a  portion  in 
the  uterus,  pro\ided  that  by  an  appropriate  antiseptic  treatment 
(iodoform  tampon,  carbohzed  intrauterine  injections,  etc.),  we 
guard  against  septicaemia  wliieh  is  Uable  to  be  caused  by  the 
gangrene  of  the  remaining  portion.  But  these  incomplete  ablations 
of  fibromata  have  given  rise  to  disaster  when  antiseptic  precautions 
were  not  taken  or  did  not  succeed.  Although  this  emergency  is 
always  unfortunate  we  can  hope  in  such  cases  for  one  of  two  termi- 
nations :  either  the  more  or  less  tardy  expulsion  of  the  remnant  of 
the  fibroma,  or  the  retraction  and  the  atrophy  of  the  intrauterine 
fragment. 

After  the  enucleation  of  an  intrauterine  fibroma  there  remains  a 
cavity,  often  quite  large,  bleeding,  traversed  by  floating  debris  and 
a  uterus  in  a  state  of  more  or  less  completed  relaxation.  The  Avound 
should  be  smoothed  by  excising  the  ragged  edges  of  the  mucosa  and 
the  fibrous  filaments.  A  hot  antiseptic  injection  is  then  given.  It 
is  better  to  use  a  carbolic  solution  (20-1000)  than  the  sublimate,  on 
account  of  the  large  absorbent  surface.  The  temperature  will  be 
raised  to  50°  C,  if  there  is  marked  oozing  of  blood.  The  cavity  may 
also  be  tamponed.  Finally,  a  hypodermic  injection  of  ergotine  to- 
gether with  massage  over  the  uterus,  wUl  cause  contractions  of  the 
organ.  A  tight  body-bandage  will  be  placed  over  small  thicknesses 
of  cotton-wool  and  the  patient  will  be  left  entirely  at  rest. 

The  principal  accidents  of  enucleation  are  hsemorrhage,  wounding 
the  uterine  waU,  and  secondarily,  septicaemia.  For  the  haemorrhage 
the  best  remedy  is  to  terminate  the  operation  rapidly.  The  slu-inking 
of  the  uterine  walls  causes  haemostasis.  If  necessary,  compression 
of  the  abdominal  aorta  and  intrauterine  tamponnement  wiU  be 
made.  Perforation  is  very  grave  only  in  case  septic  inflammation 
attacks  the  cavity.  Otherwise  an  adhesive  peritonitis  soon  closes  the 
wound,  as  after  vaginal  hysterectomy. ,  Inversion  may  be  produced 
during  the  operation  under  the  influence  of  excessive  traction  and 
may  even  facilitate  the  work  of  the  surgeoir  by  making  the  tumor 
more  accessible,  but  it  is  dangerous  if  not  recognized,  for  it  may 
lead  the  efforts  in  a  faulty  direction.  After  the  operation  the  thin- 
ness of  the  organ  has  sometimes  favored  a  secondary  inversion. 
Bischoff,  in  such  a  case,  obtained  gradual  reduction  by  aid  of  the 
tampon.  Septicaemia,  with  its  various  local  manifestations,  metro- 
peritonitis, thromboses,  etc.,  is  to  be  feared  when  a  very  large  cavity 
exists  in  consequence  of  want  of  contraction  of  the  walls  of  the 
uterus.  It  is  then  useful  to  make  repeated  intrauterme  injections 
and  antiseptic  dressings.  The  cruciform  drainage-tube  may  be  left 
in  the  uterus.  In  cases  where  the  secretion  is  very  abundant  and 
putrid  continued  irrigation  should  be  employed. 

Gravity  of  the  operation. — According  to  the  judicious  remarks  of 
West  and  of  Gillette  it  is  impossible  to  arrive  at  an  exact  idea  of 


162  Treatment  of  Fibroid  Timiors. 

the  gravity  of  euucleatiou  from  .statistics  obtained  by  combining 
all  the  published  cases.  On  the  one  hand,  successes  are  more 
frequently  pubhshed  than  failures.  On  the  other  hand,  very  dis- 
similar cases  will  be  tabulated  together,  complete  or  incomplete 
enucleations  in  one  or  more  sittings,  on  intact  or  on  gangrenous 
tumors,  treated  aseptically  or  not,  etc.  Finally  the  word  enucle- 
ation is  not  understood  in  the  same  sense  by  all  authors.  To  be 
able  to  judge  this  operation  correctly — as  well  as  all  others — it  is 
necessary  to  collect  individual  series  or  authentic  cases  from  com- 
petent surgeons  and  properly  classified.  For  the  present  we  must 
content  ourselves  with  more  or  less  incomplete  statistics.  I  had 
thus,  in  1875,  collected  sixty-four  cases  with  sixteen  deaths,  or  25 
per  cent.  Gusserow  has  been  aljle  to  collect  one  hundred  and  fifty- 
four  operations,  to  1877,  with  fifty-one  deaths,  or  33  per  cent. 
Lomer,  who  restricted  his  inquiries  to  the  antiseptic  period,  from 
1873  to  1883,  has  found  one  hundred  and  thii'ty  cases  ^vith  eighteen 
deaths,  or  16  per  cent.  FinaUy,  by  adding  to  the  statistics  of 
Lomer  some  still  more  recent  facts,  Gusserow  obtained  one  hundi-ed 
and  fifty-thi-ee  cases,  with  twenty-three  deaths,  or  14.6  per  cent. 
The  enormous  gain  accomplished  by  antisepsis  will  be  noted. 

A.  ilartiu,  out  of  twenty-seven  operations,  had  five  deaths,  two  by 
wound  of  the  peritonseum  and  peritonitis,  two  by  septiciemia  (before 
the  era  of  autisepticism),  one  death  from  collapse.  He  declares 
that  he  has  entu'ely  renounced  vaginal  enucleation  for  tumors  of 
the  body  of  the  uterus,  even  when  they  are  half  intravaginal.  He 
much  prefers  extraction  thi'ough  the  abdomen,  and  makes  an 
enucleation  that  respects  the  integrity  of  the  uteras  as  we  shall  see 
later. 

I  believe,  with  Martin,  that  the  indications  for  enucleation 
thi-ough  the  vagina  have  been  carried  too  far.  Tumors  reaching 
up  toward  the  umbilicus  are  much  better  removed  by  laparotomy. 
However,  enucleation  (alone  or  with  segmentation)  remains  a 
A^aluable  resource,  relatively  benign,  in  fibroids  of  the  cervix,  and 
for  those  of  the  inferior  j)ai-t  of  the  body  of  the  uterus,  not  exceed- 
ing the  volume  of  a  foetal  head,  and  which  have  already  commenced 
dilatation  of  the  cervix. 

Transvaginal  enudcation. — It  may  happen  that  the  myoma,  arising 
from  the  supravaginal  portion  of  the  ceiTix  or  fi-om  the  posterior 
surface  of  the  uterus,  projects  behind  the  posterior  vaginal  wall  in 
such  a  manner  that  the  most  direct  way  to  arrive  at  its  enucleation 
is  afforded  by  iucision  of  this  waU.  The  same  may  occur,  though 
more  rarely,  with  regard  to  the  anterior  cul-de-sac.  In  such  cases 
the  more  rational  operation  is  to  fi'eely  iucise  the  vagina  for  the 
extirpation  of  the  fibroma.  It  will  be  understood  that  the  pro- 
cedm-es  wiH  be  relatively  simple  for  tumors  exclusively  developed  in 
the  pelvic  connective  tissue  and  not  covered  by  the  peritonaeum. 


Treatment  of  Fibroid  Tumors.  163 

When  the  tumor  is  very  large,  it  is  better  to  add  segmentation  to 
the  enucleation.  When  the  fibroid  projects,  both  toward  the  vagina 
and  toward  the  peritoneal  cavity,  the  danger  of  opening  the 
peritonaeum  complicates  the  operation  very  much  and  renders  it 
more  grave.  There  have  been  several  deaths  due  to  consecutive 
peritonitis.     But  many  successes  have  also  been  reported. 

Segmentation  or  vaginal  myomotomy . — The  difficulty  of  enucleation, 
when  the  tumor  has  a  considerable  volume  or  close  connections  with 
the  uterus,  and  the  gravity  of  opening  the  abdomen,  compared  with 
operation  through  the  vagina,  have  caused  venturesome  surgeons 
to  undertake  the  ablation  of  successive  large  fragments,  by  the 
vagina,  through  the  cervix,  nearly  effaced  either  by  natural  dila- 
tation or  by  incision.  Emmet  has  designated  by  the  name, 
extraction  of  fibroids  by  traction,  a  procedure  that  he  has  practiced 
since  1874,  but  unfortunately  it  is  not  clearly  described.  His  aim, 
he  says,  is  to  pedunculate  the  tumor  by  traction,  and  then  he  excises 
it  by  a  mixed  procedure  of  segmentation  and  enucleation.  But  he 
describes  his  technique  in  so  imperfect  a  manner  that  it  is  difficult 
to  obtain  a  precise  idea  of  it.  The  isolated  facts  of  Czerny  and 
other  German  surgeons  are  no  better  fox'mulated  into  a  definite 
method. 

This  criticism  does  not  apply  to  the  method  that  Pean  has 
adopted.  The  chief  idea  of  his  procedure  consists  in  using  segmen- 
tation first,  as  the  initial  manoeuvre  and  not  as  an  aid  to  enucleation. 
In  place  of  attacking  the  tumor  at  its  periphery  first,  the  surgeon 
enters  the  fibroid  at  once  and  does  not  arrive  at  the  fibrous  capsule 
until  the  tumor  is  scooped  out.  More,  Bean's  operation  comprises 
a  special  preliminary  operation,  of  discision  and  even  excision  of 
the  cervix  to  allow  easy  access  to  the  fibroid.  The  cases  to  which 
tins  surgeon  has  applied  segmentation  through  the  vagina  comprise 
not  only  submucous  tumors  the  size  of  a  child's  head  at  term,  but 
also  cases  of  interstitial  and  subperitonseal  tumors,  wliich  certainly 
necessitate  opening  the  serous  membrane  largely.  Thus  in  these 
cases  Pean  has  often  been  obliged  to  terminate  the  operation  by 
total  ablation  of  the  uterus,  either  through  the  vagina  or  by  lapa- 
rotomy. This  is  perhaps  an  extreme  and  dangerous  application  of 
the  operation.  The  weak  point  of  this  operation  is  truly,  it  appears 
to  me,  in  the  difficulty  of  determing  the  limits  which  must  not  be 
passed,  and  the  possibility  of  being  obliged  to  perform  hysterectomy 
at  the  end  of  an  already  laborious  operation. 

The  operation  is  divided  into  several  stages:  1.  Liberation  of 
the  cervix  from  its  vaginal  insertions.  2.  Section  of  the  cer^dx  and 
of  the  segment  of  the  uterus  as  far  as  the  limits  of  the  tumor.  3. 
Segmentation  of  the  tumor,  followed  or  not  by  the  enucleation  of  a 
part  of  the  tumor.    4.  Excision  or  suture  of  the  cervical  lips. 

For  this  operation  Pean  employs  a  whole  series  of  forceps,  straight 


1()4 


Treatment  of  Fibroid  Tumors. 


and  curved,  with  jaws  of  various  shapes,  long,  Hat,  deutated  or  non- 
dentated,  with  or  without  i)oints,  round  or  square,  especially  designed 
for  segmentation  (Figs.  75  and  76).  Finally  it  is  necessary  to  have 
an  ample  number  of  forcipresure  forceps,  either  of  the  ordinary 
model  or  with  loug  handles.  The  preliminaries  are  the  same  as 
for  all  gynfficologieal  operations.  The  patient  is  placed  iu  the  left 
lateral  position.  Left  leg  extended,  right  leg  flexed  and  supported 
by  an  assistant.  Besides  two  other  assistants  placed,  one  to  the 
right  and  one  to  the  left,  of  the  operator,  a  fourth,  mounted  on  a 
foot-stool  and  placed  a  little  further  back  will  be  useful  to  hold  the 
retractors. 


Fig.  75. — Dentated  cyst  forceps  that  can  be  utilized  for  segmentation. 


Fig.  76. — Pean's  forceps  for  segmentation. 


First  ST.\(iE. — JAheration  of  the  neck. — Two  or  tlu-ee  curved  re- 
tractors held  by  two  assistants  uncover  the  cervix  in  the  fundus  of  the 
vagina.  The  cer^dx  is  seized  and  immobilized  with  a  strong  vol- 
sella.  A  circular  incision  is  made  with  the  loiife  at  the  vaginal 
insertion.  The  haemostatic  forceps  are  placed,  if  needed,  on  the 
bleeding  points  of  the  vaginal  surface.     This  is  the  time  when  these 


Treatment  of  Fibroid  Tumors. 


165 


forceps  are  most  necessary,  for  before  preceding  with  the  opera- 
tion it  is  important  to  obtain  complete  hsemostasis.  The  dissection 
is  carried  to  a  sufficient  lieigiit  around  the  cervix.  The  cervix  is 
encircled  near  this  with  the  knife,  especially  in  front,  so  as  not  to 
injure  the  bladder  or  the  ureters.  The  cervix  then  becomes  very 
mobile  like  the  tongue  of  a  bell.  In  this  stage  of  the  operation  care 
must  be  taken  not  to  wound  the  peritonteum.  This  accident  is  not 
so  serious,  however,  as  has  been  supposed.  In  some  cases,  accord- 
ing to  Pean,  this  perforation  is  necessary  to  reach  a  fibroid  that 
projects  into  the  cul-de-sac. 

Second  st.\gb. — Incisions  of  the  cervix  and  of  the  inferior  segment 
of  the  uterus. — Long  straight  scissors,  with  blunt  ends,  are  intro- 
duced open,  with  one  blade  in  the  cervical  cavity,  and  a  clean 
bilateral  section  is  made.  A  volsella  is  placed  on  each  lip,  ante- 
rior and  posterior.  The  finger  introduced  into  the  uterine  cavity 
indicates  the  exact  site  of  the  tumor,  the  part  Avhere  it  will  be  most 
easily  reached.  The  tumor  is  distinguished  from  the  uterine  walls 
by  its  wliitish  aspect,  and  especially  by  its  greater  density.  During 
this  exploration,  aid  may  be  obtained  by  traction  on  the  uterus. 


Fig.  77. — Segmental 


Thied  stage. — Seginentation  of  the  tumor. — The  tumor  may  be 
projecting  toward  the  uterine  cavity,  toward  the  peritonaeum,  or 
toward  the  vagina.  It  is  drawn  down  by  a  sustained  traction,  with 
the  volsella,  or  with  long  forceps  furnished  with  flat  dentated  or 


166  Treaiment  of  Fihrvid  Tumors. 

fenestrated  jaws  or  with  points  (Figs.  75  and  76).  With  these  forceps 
the  tumor  does  not  tear  so  quickly,  the  grasp  is  more  soHd.  The 
curved  retractors  are  introduced,  krge  ones  into  the  vagina,  small 
ones  into  the  uterus,  uncovering  the  field  of  operation  as  much  as 
possible.  These  retractors  serve  not  only  to  admit  light,  but  con- 
stitute at  tne  same  time  a  valuable  hasmostatic  measui-e  by  the 
pressm-e  and  the  traction  that  they  exercise.  If  needed  an  electric 
light  can  be  made  to  thi-ow  a  bright  light  on  the  field  of  operation. 
The  fibroid  tumor  is  uncovered  or  felt  ^^ith  the  finger ;  it  is  seized 
with  the  forceps  and  forcibly  drawn  doT\Tiward.  It  may  be  first 
grasped  at  one  part  by  strong  dentated  forceps ;  a  deep  incision 
pei-pendicular  to  the  long  axis  of  the  tumor  is  made ;  each  Hp  of 
this  section  is  seized  as  far  up  as  jjossible  with  the  dentated  forceps, 
or  that  ^^ith  points  m  the  jaws  ;  the  part  subjacent  to  the  forceps  is  ex- 
cised. Before  removing  the  first  pair  of  forceps  a  second  paii"  is 
fastened  above  it,  catching  a  new  part  of  the  fibroid ;  the  scissors  or 
the  knife  divide  the  parts  subjacent  to  the  preceding  pair  of  forceps. 
Thus  by  the  aid  of  the  forceps,  the  knife  and  the  scissors,  a  poi-tion  of 
the  tumor  is  extirpated  piece  by  piece.  The  knives  used  by  Pean 
are  of  very  gi-eat  strength,  resembling  small  metacarpel  laiives, 
straight  or  curved  on  the  flat,  with  long  handles. 

Quite  often,  the  proeeding  is  simpUfied.  The  myoma  does  not 
bleed,  so  that  the  use  of  the  forceps  can  be  limited  to  grasping  the 
tumor  and  drawing  it  down.  The  scissors  or  the  knife  divide  the 
tumor  above  the  fragment  seized  \\ith  the  jaws  of  the  forceps.  The 
removal  of  the  pieces  is  continued  alternately  on  the  different  parts 
of  the  tumor.  In  proportion  as  the  operation  progresses,  the  tractions 
permit  the  removal  of  larger  fragments.  These  vary  from  the 
size  of  a  nut  to  that  of  an  apple.  The  segmentation  of  some  fibroids 
is  very  simple,  each  traction  permitting  the  ablation  of  a  large  fi'ag- 
ment  of  hard  tissue,  absolutely  exsanguinated.  The  operation 
will  be  almost  bloodless  if  it  has  not  l)een  necessary  to  hberate  and 
incise  the  cervix.  The  introduction  and  M"ithdrawal  of  the  forceps 
fom"  or  five  times  permits  the  extractioai  of  successive  fragments. 
This  procedure  in  other  instances  may  require  an  hour.  WTien 
the  lower  parts  of  the  tumor  have  been  removed  it  is  sometimes 
possible  to  obtain,  by  traction  aided  by  movements  of  rotation,  the 
spontaneous  enucleation  of  the  remaining  part,  the  length  of  the 
operation  may  thus  be  materially  diminished. 

According  to  Pean,  segmentation  aided  by  enucleation  permits 
the  ablation  of  a  tumor  equal  to  or  greater  than  that  of  a  foetal 
head  at  term.  'When  the  fibroid  presents  such  a  thickness,  the 
intra-miiscular  layers,  which  envelope  it,  are  almost  always  ex- 
tensively opened,  communicating  with  the  interior  of  the  uterus  and 
peritonaeum,  and  bleeding  so  freely  that  it  may  be  necessary  to  place 
forceps  on  the  large  vessels.     Tliis  stage  of  the  operation  then 


Treatment  of  Fibroid  Tumors.  167 

necessitates  the  dissection  of  all  the  lower  part  of  the  uterus  in  such 
a  way  as  to  free  the  organ  and  permit  it  to  be  drawn  down  near 
the  vulva.  If  necessary,  to  faciUate  the  procedure,  Pean  excises  the 
two  lips  of  the  cervix  and  sutures  them  finally  to  the  lips  of  the 
wound  made  in  the  mucosa  of  the  vaginal  culs-de-sac.  He  makes 
tliis  suture  with  metallic  threads.  With  regard  to  the  communica- 
tion which  exists  with  the  peritonasal  cavity,  Pean  leaves  it  open  or 
if  too  much  bruised  draws  it  together  with  a  few  interrupted  sutures. 
It  is  not  difficult  to  perceive  the  point  where  the  ablation  is  com- 
plete ;  the  last  portions  extracted  by  traction  and  enucleation  offer 
a  convex  surface,  smooth,  red,  covered  with  small  cellular  debris. 
This  stage  of  the  operation  is  not  complete  until  the  surgeon  has 
taken  exact  account,  with  the  finger,  of  the  state  of  the  contiguous 
uterine  structures.  If  a  new  myoma  is  found  near  the  first,  he 
should  proceed  at  once  to  its  extraction.  He  will  have  recourse  to 
a  more  extensive  division  of  the  uterus  if  necessary,  arriving  thus 
at  this  tumor,  proceeding  to  its  segmentation  as  before.  Thus,  the 
operator  may  find  it  a  necessity  to  remove  a  series  of  small  tumors 
from  the  parenchyma.  Hysterectomy  will  be  indicated  in  case  the 
uterine  incisions  thus  produced  would  be  too  extensive.  The  idea  of 
making  a  complete  operation  should  always  be  kept  in  view.  Opera- 
tion at  a  single  sitting  is  much  preferable  to  su.ccessive  seances. 

Fourth  stage. — Toilet  of  the  uterus;  Suture  of  the  cervix. — As  soon 
as  the  tumor  has  been  removed,  there  remains  a  large  pocket,  which 
communicates  freely  with  the  uterus.  Haemostatic  forceps  with 
long  handles  are  fastened  on  the  bleedmg  points  and  left  remaining, 
to  the  number  of  twelve,  fifteen  or  twenty.  The  forceps  are  not 
placed  blindly.  During  the  operation  small  sponges,  carried  in 
sponge  holders,  are  used  by  Pean  to  cleanse  the  walls  and  to 
discover  the  bleeding  points  (I  replace  them  with  tampons  of 
absorbent  cotton).  Tliis  last  part  of  the  operation  consists  of  the 
toilet  of  the  operative  field  and  should  be  executed  with  care.  The 
smallest  clots  should  be  removed.  Between  the  forceps  that  are  left 
remaining,  as  an  hsemostatic  measure,  it  is  prudent  to  place  some 
tampons  of  iodoform  gauze.  An  intrauterine  irrigation  of  a  hot 
antiseptic  solution  should  precede  the  application  of  these  tampons. 
The  forceps  are  removed  thirty-six  to  forty-eight  hours  after  the 
operation.  In  cases  where  the  tumor  is  small  and  its  capsule  of 
small  extent,  the  operation  may  be  terminated  by  suturing  the  lips 
of  the  cervix.  During  the  first  few  days  that  follow,  it  is  well  to 
give  small  doses  of  ergot. 

It  is  difficult  to  pronounce  on  the  gravity  of  segmentation  of  fibro- 
mata by  this  method.  Pean  has  not  published  his  entire  statistics. 
TerriUon,  out  of  five  operations,  has  had  five  successes;  Bouilly, 
four  out  of  five.  I  have  been  successful  in  the  single  case  in  which 
I  have  employed  it.     It  appears  to  me  certain  that  this  bold  pro- 


168  Treatment  of  Filiroid  Tumors. 

cedure  should  give  excellent  results  when  the  tumor,  even  vei-y  large, 
is  always  submucous  or  markedly  interstitial,  furnished  with  a 
capsule  which  permits  a  clean  enucleation  of  the  superior  part  of 
the  tumor.  But,  if  one  attacks,  either  at  once,  or  secondaiily,  a 
subperitouffial  tumor,  or  one  so  intimately  fused  with  the  uterine 
parenchyma  that  there  is  no  clear  demarcation  Itetween  the  patho- 
logical and  the  normal  tissue,  it  is  evident  that  the  operation 
becomes  very  grave  and  leads  almost  surely  to  a  vaginal  hyster- 
ectomy made  in  bad  conditions.  Although,  in  a  daring  operation, 
Mikulicz  has,  immediately  after  operative  inversion,  resected  a 
poi-tion  of  the  uterine  wall  to  remove  a  tumor  of  this  kind,  then 
sutui'ed  the  periton»al  wound  of  ten  centimetres,  replaced  the 
uterus  and  cured  his  patient,  stUl  Ave  would  not  hold  tliis  up  as  an 
example  to  be  followed. 

It  is  not  a  sufficient  recommendation  that  an  operation  may  be 
possible  and  even  that  it  may  have  given  briDiant  results,  it  is  more 
especially  necessary  for  it  to  be  preferable  to  all  other  operations 
which  can  be  made  in  the  same  case ;  that  is  to  say,  it  must  be 
less  fatal.  Now,  in  the  absence  of  comparative  statistics,  it  does 
not  appear,  a  priori,  probable  that  segmentation  of  very  large 
fibromata,  through  the  vagina,  is  simpler  and  less  dangerous  than 
abdominal  hysterectomy  or  intra-abdominal  enucleation  (Martin). 
Besides,  it  should  be  said,  that  the  temperament  and  the  methods  of 
the  sm-geon  often  play  here  an  important  role. 

Vaginal  hysterectomy. — The  total  ablation  of  the  uterus  for  fibro- 
mata has  been  advised  in  two  different  circumstances  :  1.  In  cases 
of  small  tumors,  simple  or  multiple,  giving  rise  to  serious  sjTnptoms. 
2.  In  cases  of  large  tumors,  when  at  the  end  of  segmentation  there 
is  a  certainty  that  a  portion  of  the  uterine  wall  must  be  removed ; 
it  is  then  an  operation  of  necessity  on  which  I  shall  not  enlarge. 
In  small  tumors,  on  the  contrary,  the  operation  of  hysterectomy, 
performed  by  choice,  has  still  only  a  few  partisans  and  the  majority 
of  surgeons  prefer,  justly  I  believe,  a  less  serious  procedure,  cas- 
tration. It  appears  that  here  again  indi\-idual  preferences  are 
preponderant.  Thus,  for  example,  Pean  prefers  to  make  a  vaginal 
hysterectomy  for  the  same  cases  in  which  some  authors  practice' 
al)dominal  hysterectomy  and  stiD  others  ovarian  castration.  In 
fact  either  of  these  thi-ee  operations  has  good  chance  of  success  only 
in  cases  of  small  and  multiple  fibromata. 

Colpo-hysterectomy  for  fibromata  was  fii-st  systematized  into  a 
method  by  Kottmaun.  According  to  Galabin,  out  of  forty  cases  of 
vaginal  hysterectomy  there  were  only  two  deaths,  or  1-1.29  per  cent. 
Leopold,  out  of  seventeen  operations,  had  only  two  deaths.  Several 
times  this  operation  was  performed  for  tumors  having  the  volume 
of  the  foetal  head  at  term.  The  operative  technique  is  to  be 
described  in  vaginal  hysterectomy  for  cancer.     It  is   only  to   be 


Treatment  of  Fibroid  Tumors.  169 

remarked  here  that  the  segmentation  offers  no  clanger  of  infection 
for  the  wound,  the  neoplasm  (except  in  suppuration  or  gangrene) 
not  being  septic.  Great  benefit  may  be  derived  from  section  of  the 
uterus  or  from  segmentation  of  the  tumor  in  facilitating  its  extraction. 
Eecourse  may  also  be  had  either  to  a  previous  dilatation  of  the  vagina 
and  vulva  (Pean),  or  to  incisions  in  these  regions  (Mikulicz,  Leo- 
l^old)  that  it  will  be  necessary  to  restore  at  the  close  of  the  operation. 
I  will  note  the  absolute  necessity  of  making  the  hysterectomy 
complete,  without  leaving  in  the  abdomen  even  one  fragment  of  the 
uterine  tissue  adherent  to  the  broad  ligament.  The  decomposition 
of  such  a  fragment  has  caused  death  by  peritonitis. 

Tliis  method  of  treating  fibromata,  it  appears  to  me,  should  be 
reserved  for  cases  where  the  uterus,  relatively  small  but  compro- 
mising important  organs,  can  be  extracted  without  great  effort  and 
without  prolonged  segmentation  with  easy  ligature  of  the  broad  Hga- 
ments.  It  is  only  in  this  way  that  the  operation  is  benign  and  can  be 
substituted  for  abdominal  hysterectomy.  To  be  more  explicit,  I 
would  counsel  vaginal  hysterectomy  in  cases  where  the  uterus  does 
not  notably  surpass  the  size  of  the  fist,  and  in  the  following  cir- 
cumstances:  1.  Haemorrhage  threatening  fatal  termination  if  not 
immediately  controlled.  2.  Serious  pressure-effects  (on  the  ureter, 
bladder,  nerves,  rectum)  exercised  by  a  smah  pelvic  fibroma,  on 
the  development  of  which  the  indirect  action  of  castration  will  be 
too  long  or  perhaps  insvifficient.  In  all  other  cases,  if  the  tumor 
cannot  be  enucleated  through  the  vagina  or  through  the  abdomen 
by  respecting  the  uterus,  I  would  prefer  castration  for  hemorrhagic 
accidents  and  abdominal  hysterectomy  when  the  size  and  connec- 
tions of  the  tumor  require  extirpation  of  the  organ.  In  spite  of  the 
undeniable  dangers  of  laparotomy  a  simple  abdominal  hysterectomy 
will  always  be  less  grave  than  a  very  laborious  vaginal  hysterectomy. 
Destruction  of  fibromata  through  the  I'agina. — I  will  unite  under  this 
head  the  different  operations  that  do  not  enter  into  the  preceding 
class  and  which  should  be  noted  historically.  Partial  destruction 
by  Baker  Brown's  method ;  incision  of  the  capsule ;  introduction 
into  the  depth  of  the  fibroid  with  special  scissors,  cutting  by  their 
external  border  and  discision  of  the  mass ;  at  other  times  ablation 
of  conoidal  fragments  or  perforation  with  a  kind  of  trepan ;  partial 
destruction  by  cauterization.  Greenhalgh,  for  the  same  object,  in- 
cised the  capsule  with  the  actual  cautery  and  when  suppuration  was 
established,  removed  the  debris  with  the  hand.  In  eases  of  retro- 
vaginal  tumors  he  perforated,  with  the  actual  cautery,  the  points 
that  projected  most  into  the  vagina.  In  two  cases  out  of  three  death 
followed  from  peritonitis.  Koeberle's  procedure  can  be  classed  here. 
He  dilates  the  cervix  and  then  makes  a  series  of  parallel  incisions 
into  which  he  throws  a  sufficient  quantity  of  perchloride  of  iron  to 
determine  death  of  the  interposed  layers. 


170  Treatment  of  Fibroid  Tumors. 


CHAPTER  XL 


TREATMENT   OF   FIBROID   TUMORS   OF   ABDO- 
MINAL EVOLUTION.  — MYOMECTOMY 
AND   HYSTERECTOMY. 

The  ablation,  thi-ough  the  abdomen,  of  fibroid  tumors  projecting 
into  this  cavity,  or  hysterectomy,  is  the  daughter  of  ovariotomy. 
Tliis  operation  at  first  was  not  premeditated ;  it  was  the  result  of 
errors  of  diagnosis.  After  having  opened  the  abdomen  to  remove 
tumors,  presumably  ovarian,  some  surgeons  found  themselves  ui 
the  presence  of  uterine  fibromata.  The  first  who  committed  this 
mistake  shrank  from  the  dangers  of  an  unknown  operation,  they 
hastened  to  close  the  abdomen  without  completing  the  operation. 
Others,  however,  had  the  courage  to  extu-pate  subserous  peduncu- 
lated fibroids.  Clay  and  Heath  in  1843,  then  Burnham  in  1853, 
iindertook  the  first  partial  amputations  of  the  utei-us.  Gihnann 
Kimball  was  the  first  surgeon  who  made  a  hysterectomy  for  an  inter- 
stitial fibroid  giAdng  rise  to  -sdolent  hfemorrhages.  The  patient  was 
cured.  Koeberle  was  only  the  second,  but  the  exact  determination 
of  diagnosis,  the  rational  choice  of  an  operative  technique  and  the 
absolute  novelty  of  the  subject  in  Europe,  gave  to  his  observation 
an  exceptional  value.  It  is  the  work  that  he  published  at  this  time 
that  truly  made  hysterectomy  the  order  of  the  day. 

Koeberle  was  the  originator  of  the  hgature  of  the  pedicle  with 
a  metallic  loop  and  the  serre-noeud,  which  was  a  considerable 
advance  over  the  ligature  en  masse  with  tlu'ead,  which  had  been 
practiced  to  that  time.  From  this  time  the  isolated  facts  multiplied. 
From  1866,  Caternault,  a  pupil  of  Koeberle,  published  forty-two 
observations  of  amputation  of  the  utenis  and  twenty  cases  of 
gastrotomy  with  extirpation  of  pedunculated  tumors.  Many  authors, 
in  place  of  the  serre-nceud,  employed  at  that  time  the  ecraseur  and 
the  clamp.  The  eminent  surgeon  of  Strassburg  had  scarcely  made 
known  his  operations  when  Pean  followed,  with  rare  good  fortune, 
in  the  same  path.  The  presentation  of  a  patient  that  he  cured  to 
the  Academic  de  Medecme  (August,  1870),  then  three  years  later  the 
publication  of  an  important  work  in  which  the  rules  for  operation 
were  established  with  a  precision  until  then  unknown,  has  hnked 
the  name  of  Pean  to  that  of  hysterectomy  with  extra-peritona?al 
treatment  of  the  pedicle.  The  technique  consisted  especially  in  the 
extensive  employment  of  forcipressure  (which  Koeberle  was  then 
the  only  one  to  use  as  fi-eely),  in  the  segmentation  of  large  tumors 


Treatment  of  Fibroid  Timwrs.  171 

after  metallic  ligature  in  order  not  to  enlarge  the  abdominal  opening, 
in  the  external  fixation  of  the  pedicle  by  long  needles  passed 
tln-ough  it,  and  by  a  loop  of  iron  wire  applied  with  the  ingenious 
serre-noeud  of  Cintrat. 

After  this  first  stage  in  the  progress  of  hysterectomy  it  is  con- 
venient to  distinguish  a  second.  This  was  characterized  by  the 
application  of  antiseptic  procedures  to  this  operation  as  to  all  those 
of  general  surgery.  Finahy  a  tliird  phase  has  been  inaugurated  by 
perfecting  the  technique  and  in  particular  by  the  introduction  of  the 
elastic  ligature  for  temporary  or  definitive  Iwemostasis.  The  most 
marked  features  of  this  period  are  the  struggle  between  intra-  and 
extra-peritonseal  treatment  and  the  event  of  castration  as  a  substitute 
for  hysterectomy  in  a  great  number  of  cases. 

Synonymy. — It  is  necessary  to  understand  first  of  all  the  value  of 
the  words.  The  term  hysterotomy,  which  signifies,  etymologically, 
section  of  the  uterus,  is  essentially  comprehensive.  With  the 
qualification  abdominal  it  can  be  applied  to  any  operation  whatever 
where  the  uterine  tissue  is  incised  after  opening  the  abdomen.  An 
other  precise  term  is  supravaginal  hysterectomy,  which  plainly 
inphes  section  and  ablation  of  the  uterus  above  the  vagina.  Tillaux, 
in  1879,  proposed  the  use  of  the  word  hysterectomy  for  the  cases 
where  a  part  or  the  whole  of  the  organ  is  removed.  This  more 
exact  term  prevailed  rapidly,  although  the  old  word  is  still  met  with 
quite  often.  The  Germans  use  myomotomy  or  myomectomy  when 
all  or  part  of  the  uterus  is  respected.  Finally,  imder  the  name  of 
enucleation  (intra-peritonseal),  are  comprehended  the  cases  where  a 
simple  incision  into  the  uterine  walls  permits  removal  of  the  tumor 
and  conservation  of  the  whole  of  the  organ. 

General  indications  for  abdominal  hysterectomy. — We  will  see  later 
that  the  possibility  of  substituting  for  this  grave  operation  another 
procedure  which  is  less  fatal  (castration),  reduces,  in  certain  cir- 
cumstances, the  field  of  hysterectomy.  However  that  may  be,  we 
can  formulate  the  indications  for  abdominal  hysterectomy  as 
follows :  Rrapid  increase ;  galloping  progress  of  tumor ;  serious 
hemorrhages,  that  do  not  yield  to  any  palliative  ;  ascites,  produced 
by  the  irritation  of  a  very  mobile  fibroid ;  compression  of  the  organs 
contained  in  the  pelvis  or  in  the  abdomen ;  considerable  volume  of 
the  tumor,  and  in  particular  its  cystic  degeneration,  oedematous  or 
suppurative;  symptomatic  prolapsus  of  the  uterus;  pregnancy, 
when  the  fibroid  would  be  manifestly  a  serious  cause  of  dystocia. 

The  classification  that  can  be  established  in  view  of  operation 
through  the  abdomen  is  the  following :     I.    Pedunculated  fibroids 

II.  Fibroids  of  a  single  nucleus  (or  predominantly  so),  enucleable. 

III.  Fibroids  of  multiple  nuclei.  IV.  Intra-ligamentatous  and  pelvic 
fibroids.  For  the  first  class  the  ablation  of  the  tumor  is  of  extreme 
simplicity,  and  scarcely  differs  from  that  of  ovariotomy.     This  is 


172  Treatment  of  Fibroid  Tumors. 

what  should  be  exclusively  called  myomectomy.  For  the  second 
and  tliii'd  class  partial  hysterectomy  or  supravaginal  hysterectomy 
will  generally  he  undertaken,  according  to  the  disposition  of  the 
tumors.  In  certain  cases,  intra-peritomeal  enucleation  can  be  made. 
For  the  fourth  class  an  intra-hgamentous  decortication  should  be 
made  when  recourse  to  a  palHative  operation,  castration,  eaimot  be 
had.  Finally,  total  extirpation  thi'ough  the  abdomen  has  been 
practiced  for  some  multiple  myomata  extending  to  the  cervix,  ^\ith 
such  hypertrophy  of  the  tissues  that  any  conservation  of  the  stumjjs 
is  impossible. 

Before  passing  in  review  these  different  operations  and  their 
varieties,  I  w'ill  say  something  of  an  operative  manceuvre  appHcable 
to  all  and  which  has  completely  changed  the  conditions  of  the 
technique  since  its  introduction  into  abdominal  surgery. 

Provisional  hcemostasls. — Whatever  the  nature  of  the  operation 
performed  in  the  abdomen  on  the  uterus,  it  is  very  valuable  to  be 
able  to  accomplish  it  without  loss  of  blood.  Older  operators  employed 
to  this  effect  constriction  \nth  the  ecraseur.  Billroth  constructed  a 
special  forceps.  A  valuable  means  of  provisional  hsemostasis  is 
afforded  by  the  temporary  elastic  ligature.  Kleeberg,  of  Odessa, 
was  the  first  to  employ  the  elastic  rubber-cord  as  a  Hgature  to  the 
uterine  pedicle  m  the  place  of  the  metallic  wu-e  used  by  Koeberle 
and  Pean.  Martin  has  sj'stamatized  Kleeberg's  procedure  by  making 
the  ru-bber  Ugature  fulfill  in  uterine  surgery  the  role  that  Esmarch's 
bandage  plays  in  general  surgery. 

In  Germany  rubber  tubing  of  a  thickness  of  about  five  millimetres 
is  generally  used.  I  prefer  the  plain  cords  of  five  millimetres 
diameter,  and  they  have  been  generally  adopted  in  France.  It  is 
easier  to  be  assured  of  their  asepsis  and  in  equal  sizes  they  are  more 
resisting.  For  provisional  Hgature  the  elastic  cord  is  strongly 
stretched  and  carried  two  or  tlu-ee  times  around  the  part  it  is 
intended  to  constrict. 

I.  Peduncidateil  fbromata ;  Myomectomy.  —  First  an  elastic  lig- 
ature, designed  to  ensure  temporary  htemostasis,  is  placed  on  the 
uterus  as  low  as  possible  by  depressing  the  broad  ligaments.  Then,  if 
the  pedicle  is  thin,  it  is  sufficient  to  pass  a  needle  mth  a  double  silk 
tlu-ead  through  it,  and  tie  the  two  ends  with  a  Bantock  or  Lawsou 
Tait  knot  (Fig.  16).  If  not  famihar  ^nth  tliis  special  knot,  the  loop 
may  be  cut  and  the  ends  tied,  to  the  right  and  left,  after  having 
crossed  them  by  a  half  turn.  The  thr-ead  should  always  be  passed 
twice  through  the  loop  to  make  the  surgeon's  knot. 

If  the  pedicle  is  thick  it  will  be  well  to  gi-asp  it  with  BiUroth's 
large  clamp  and  compress  it  strongly  while  the  fibroid  is  separated 
by  a  cut  a  finger's  breadth  above  it,  taking  care  to  leave  a  sort  of 
collar  of  peritonaeum  and  of  cortical  substance.  The  clamp  is  then 
removed  and  in  the  groove  that  it  has  caused  on  the  pedicle  there 


Treatment  of  Fibroid  Tumors.  173 

are  placed  a  series  of  silk  sutures.  The  excess  of  tissue  that  was 
left  above  the  compressed  part  is  excised,  saving  ouly  Avhat  is  neces- 
sary to  exactly  cover  the  wound,  which  is  brought  together  with 
sutures  previously  passed  and  some  superficial  stitches.  The  pro- 
visional elastic  ligature  is  withdrawn  and  if  the  blood  oozes  by  the 
sutures,  some  deep  ones  are  added.  If  at  the  moment  of  section  of 
the  tissues,  it  has  been  possible  to  see  some  of  the  vessels,  they  may 
be  ligated  separately.  It  is  only  when  assured  that  all  sanguineous 
oozing  has  been  arrested  that  the  pedicle  is  abandoned  to  the 
abdominal  cavity.  If  there  are  still  doubts  as  to  the  hsemostasis, 
the  Wolfler-Hacker  method  is  employed,  permitting  tamponnement 
of  the  stump. 

Especially  in  pedunculated  fibrous  tumors  we  find  ourselves  in 
the  presence  of  extensive  ad- 
hesions to  the  intestmes,  form- 
ing true  adventitious  vascular 
roots,  more  important  than  the 

pedicle.     To  detach  these  ad-    /  ^  ^' 

hesions,  when  they  are  ulti- 
mate, we  use  the  procedure 
recommended  by  Schroeder; 
the  superficial  or  peritonseal 
layer  of  the  fibroid  is  left  ad- 
herent to  the  intestine  and  Fig.  78.  —  Suture  orr^all  section  of  a 
several  tlrreads  of  catgut  are  fibroid  adherent  to  the  intestines  and  resulting 
-■  1111  from  an  intimate  adhesion.     I,  Intestine;  P, 

so  passed  as  to  close  the  raw  Peritonaeal  covering  from  the  fibrrid ;  S,  Silk 
surface  (Fig.  78) .  or  catgut  thread. 

II.  Fibroids  ivith  a  single  nucleus  (or  preponderating),  encapsulated; 
Intraperitonceal  enucleation. — These  are  also  relatively  exceptional 
cases.  Most  often  fibroids  are  multiple  deforming  a  notable  segment 
of  the  uterus.  To  make  enucleation  of  the  numerous  nuclei,  and  to 
treat  each  pocket  resulting  from  this  procedure  is  not  possible.  But 
it  is  different  when' the  tumor  is  solitary,  whether  it  be  formed  by  a 
single  or  an  agglomerated  mass,  whether  it  be  interstitial  or  sub- 
mucous. Then  we  can  conceive  and  realize  the  project  of  removing 
by  enucleation  the  single  neoplasm,  by  respectmg  the  integrity  of 
the  uterus  and  its  appendages,  so  that  the  woman's  genital  life  wiU 
not  be  interrupted.  This  consideration  has  weight  only  when  it 
relates  to  a  patient  not  near  her  menopause.  It  will  then  be 
exceptionally  performed.  More  fi'equently  enucleation  will  only  be 
considered  as  a  simplification  of  the  operative  technique  applicable 
to  ceriaiu  cases. 

The  operation  begins  by  drawing  the  uterus  up  on  a  bed  of  com- 
press-sponges and  by  placing  around  the  cervix  an  elastic  cord, 
confining  the  two  ends  by  a  pair  of  forceps  or  by  my  ligator.  Having 
thus  ensured  provisional  hsemostasis,  the  uterus  is  incised  over  the 


174 


Treatment  of  Fibroid  'Tumors. 


projection  of  the  tumor  and  the  fibroid  enucleated,  if  possible,  with- 
out penetrating  the  uterine  cavity.  As  this  procedure  has  often  been 
performed  for  submucous  fibroids,  the  uterine  cavity  has  frequently 
been  opened  (ten  times  out  of  sixteen,  Martin).  In  this  event  Martin 
reunites  the  mucosa  by  a  continued  suture  of  catgut.  The  opening 
in  the  uteriue  wall  is  closed  by  a  series  of  sutures  buried  deeply 
under  the  whole  extent  of  the  wound.  At  present,  Martin  makes 
all  these  sutures  with  juniper  catgut,  in  place  of  the  carbohzed  silk 
that  he  formerly  employed  (Fig.  79).  When  the  cavity  resulting 
from  the  enucleation  appears  too  great,  Martin  places  in  it  the 
drainage  tube,  of  the  two  crossed  pieces  of  rubber  tubing,  passing 
the  extremity  through  the  cervix  into  the  vagina.  Freund,  in  a 
remarkable  case,  inasmuch  as  there  was  an  inflamed  fibroid,  re- 
placed the  rubber  tube  with  iodoform  gauze  and  tamponed  the 
uterine  cavity.  The  cavity  resulting  fi'om  the  enucleation  can  also 
be  diminished  by  resecting  portions  of  it. 


Fig.  79. — A,  enucleation  of  an  interstitial  myoma: 
B,  suture  after  enucleation. 


Martin  counsels  castration  in  case  of  suspicion  of  another  fibrous 
nucleus  in  the  uterine  walls  that  is  inaccessible.  Out  of  sixteen 
cases  he  has  had  three  deaths.  Once,  he  was  obhged  to  perform  a 
consecutive  supravaginal  amputation  of  the  uterus,  in  consequence 
of  the  development  of  a  new  fibroid,  the  nucleus  having  passed 
uuperceived  during  the  fu'st  operation.  This  event  is  e\"idently  the 
weak  point  of  this  method.  To  avoid  it,  castration  should  always 
be  combined  with  the  enucleation.  But,  then  enucleation  looses  its 
chief  end,  that  of  maintaining  the  genital  functions  intact,  and  the 
operation  becomes  a  simple  case  of  partial  hysterectomy  with  intra- 
peritonseal  treatment  of  the  pedicle. 


Treatment  of  Fibroid  Timwrs.  175 

III.  Fibroids  of  multiple  nuclei;  Supravaginal  hysterectomy. — 
According  to  Schroeder  it  is  necessary  to  distinguish  two  different 
cases,  according  as  the  fibroid  is  situated  at  the  level  of  the  fundus 
above  the  appendages,  the  body  of  the  uterus  being  almost  intact, 
or  as  the  body  of  the  uterus  is  invaded  in  such  a  way  that  the 
appendages  are  lifted  up  by  the  tumor,  at  the  side  of  which  they 
form  a  sort  of  appendix  more  or  less  sessile.  In  the  first  case,  the 
rule  is  not  to  detach  the  broad  hgaments,  thus  making  the  operation 
more  rapid  and  less  grave.  But,  as  one  can  never  be  sure  that 
there  does  not  exist  in  the  rest  of  the  uterus  one  or  more  small 
nuclei,  in  the  process  of  evolution,  it  is  prudent  to  perform  extir- 
pation of  the  ovaries  as  the  last  stage  of  the  operation.  Thus  there 
is  not  generally  obtained  a  pedicle  as  narrow  as  in  ablation  of  the 
whole  body  of  the  uterus.  This  reason  would  be  sufficient  for  the 
rejection  of  partial  hysterectomy,  if  one  serious  consideration  did 
not  plead  in  its  favor,  at  least  for  the  partisans  of  intra-peritongeal 
treatment.  Tliis  is  the  possibility  of  performing  the  operation  with- 
out opening  the  uterine  cavity,  permitting  reduction  of  the  jjedicle 
into  the  abdominal  cavity  by  considerably  diminisliing  the  chances 
of  infection.  Thus  the  distinction  established  by  Schroeder  is 
legitimate,  at  least  in  that  which  concerns  the  application  of  his 
procedure.  But  it  loses  much  of  its  value  for  the  supporters  of 
extra-peritonseal  treatment  of  the  pedicle,  among  whose  numbers  I 
place  myself. 

Partial  hysterectomy  presents  no  essential  difference  from  supra- 
vaginal amputation,  with  the  exception  of  the  absence  of  the  stage 
which  consists  in  detachment  of  the  broad  ligaments.  The  pro- 
visional elastic  ligature  is  made  below  the  tumor,  which  is  removed 
with  the  capsule  that  contains  it,  preserving  a  collar  of  peritonaeum 
and  subserous  tissues.  This  operation  is  distinguished  from 
enucleation  in  that  the  tumor  is  largely  removed  at  once  by 
encircling  it  with  the  knife.  Biit  this  should  never  be  resorted  to 
at  once,  I  advise  a  preliminary  vertical  incision  to  assure  that 
enucleation  is  not  possible,  for  if  so  it  is  then  preferable.  The 
pedicle  is  treated  by  one  or  other  of  the  methods  applied  to  supra- 
vaginal hysterectomy. 

Hysterectomy  or  supravaginal  amputation  is  the  typical  amputation 
and  one  to  which  we  have  recourse  in  the  majority  of  cases,  either 
at  once,  or  after  having  vainly  attempted  a  more  conservative 
operation — enucleation  or  partial  hysterectomy.  The  two  methods, 
according  to  the  preference  of  surgeons,  are  :  1.  That,  in  which  the 
pedicle  is  treated  externally  to  the  abdominal  wall,  the  extra-perito- 
naeal  treatment,  to  which  are  attached  the  names  of  Koeberle  and  of 
Pean,  the  originators,  and  of  Hegar  who  brought  it  to  a  high  degree 
of  perfection.  2.  The  method  in  which  the  pedicle  is  left  in  the 
peritonseal  cavity,  the  intraperitonaeal  treatment,  which  Sclu'oeder 


176  Treatment  of  Fihruhl  Tumors. 

has  made  his  own,  but  which  many  other  authors  have  used  mth 
modifications.  Fmally,  I  will  describe  a  mixed  method  that  has  the 
advantage  of  including  the  cervix  in  the  ablation  of  the  uterus,  that 
is,  total  hysterectomy. 

Technique  of  supravaginal  hysterectomy. — The  first  stages  of  the 
two  methods  intra-  and  extra-i^eritoneeal  are  the  same.  The 
abdomen  is  rapidly  opened  through  the  linea  alba  without  stopping 
to  place  forceps  on  the  small  vessels,  in  particular  the  veins  which 
bleed  during  the  first  moments  but  on  contact  with  the  air  are 
spontaneously  closed.  If  the  tumor  is  small  and  has  a  marked 
development  on  the  pelvic  side,  the  incision  should  be  extended  to 
the  pubes,  talung  the  precaution  to  be  assured  of  the  situation  of 
the  bladder  by  means  of  a  sound.  Elongations  of  this  organ  in  front 
of  the  tumor  are  to  be  feared.  To  admit  more  light  one  of  the  recti 
muscles  may  sometimes  be  di-\dded.  If  the  tumor  is  very  large  and 
soft  its  volume  may  sometimes  be  diminished  by  the  puncture  of 
cystic  cavities.  In  other  cases  it  is  better  to  prolong  the  incision  to 
the  xiphoid  appendix,  if  necessary,  than  to  proceed  by  the  long, 
difficult  and  perilous  process  of  segmentation,  formerly  advised  by 
Pean. 

It  is  then  necessary  to  disengage  the  uteinas  so  that  the  elastic 
Hgature  for  provisional  hsmostasis  can  be  appUed.  The  relations 
of  the  bladder  to  the  tumor  should  again  be  ascertained,  as  it  may 
happen,  even  to  experienced  surgeons,  that  the  ligature  will  incliKle 
a  fragment  of  this  organ.  To  protect  the  bladder  in  diSicult  cases, 
Albert  places,  at  the  start,  a  long  pin  thi-ough  the  tumor  just  above 
the  organ,  in  such  a  way  as  to  prevent  the  elastic  ligature  from 
slipping  down  on  it. 

The  broad  ligaments  are  then  cut  between  a  chain  of  double 
ligatures.  For  this  a  blunt  needle,  either  straight  or- a  little  cmwed 
toward  the  point,  is  used,  or  else  Deschamps'  needle.  The  tube 
and  round  ligament  are  ligated  separately.  On  liberating  the 
superior  part  of  the  cervix  the  elastic  ligature  is  placed  there. 
Some  authors  advise  going  ^ovm  to  search  for  the  uterine  arteries 
at  once,  attempt  being  made  to  feel  their  pulsation  or  then-  pro- 
jection on  the  sides  of  the  uterus.  It  ^nU  be  necessary  to  descend 
to  the  folds  on  either  side  of  Douglas'  cul-de-sac  and  draw  them  a 
finger's  breadth  away  from  the  cervix  to  avoid  the  ureters.  This 
ligature  is  en.  masse  and  comprises  a  small  portion  of  the  contiguous 
parts,  that  is  included  with  the  artery  in  passing  a  blunt  needle. 
This  is  only  necessary  when  the  elastic  ligature  is  not  suflicient  and 
should  be  removed  as  in  the  methods  of  intra-peritonseal  treatment 
of  the  pedicle.  One  of  the  great  advantages  of  the  extra-peritom^al 
method,  it  appears  to  me,  consists  in  being  able  to  dispense  with 
this  dangerous  stage  of  the  operation. 

It  is  always  better  to  I'emove  the  appendages.     Some  operators. 


Treatment  of  Fibroid  Tumors  177 

it  is  true,  attach  little  importance  to  leaving  them  in  situ,  believing 
that  atrophy  takes  place  after  hysterectomy,  but  it  is  always  prefer- 
able. In  fact  accidents  have  been  noted,  pelvic  hsematocele  (Pean, 
Koeberle),  extra-uterine  pregnancy  (Koeberle),  that  should  lead  to 
simultaneous  castration,  when  it  does  not  offer  difficulties  in  con- 
sequence of  extensive  adhesions. 

When  the  uterus  is  thus  sufficiently  freed  from  its  peripheral 
attachments,  the  elastic  cord  is  placed  on  the  cervix  and  the  tumor 
is  excised.  A  primary  antero-posterior  incision  divides  it  freely  to 
a  finger's  breadth  from  the  haemostatic  ligature,  then  the  fibroid  is 
rapidly  removed  by  section  and  eni\oleation.  From  this  time  the 
course  pursued  will  differ  according  as  he  intends  to  follow  Hegar's 
example  (extra-peritonseal  treatment  of  the  pedicle)  or  that  of 
Schroeder  (intra-peritonsal  treatment. 

Intra-peritonaal  method. — In  describing  this,  I  will  conform  to 
Shr-oeder's  technique  as  described  by  his  pupil  Hofmeier.  In  pro- 
ceeding with  the  ablation  of  the  tumor  care  will  be  taken  to  finish 
by  a  circular  incision,  distant  from  the  ligature  by  at  least  three 
centimetres,  carried  first  on  the  peritonaeum  and  going  deeper  only 
after  having  detached  this  membrane  a  little,  in  such  a  manner  that 
the  collar  of  tissue  saved  is  formed  in  part  by  the  serous  membrane. 
This  is  then  trimmed  with  the  scissors  in  such  a  way  that  it  may  be 
made  to  cover  the  surface  of  the  wound  by  a  slight  traction.  On 
the  surface  of  the  wound,  the  gaping  vessels  that  can  be  found  are 
ligated  with  catgut. 

An  important  stage  is  the  destruction  and  the  disinfection  of 
the  cavity  of  the  uterine  mucosa  in  the  bottom  of  the  wound.  It 
cannot  be  doubted  that  this  opening  of  tlie  uterus  constitutes  an  un- 
favorable element  of  the  intra-peritonseal  treatment,  for  infection 
may  proceed  from  it.  Some  authors,  Martin,  for  example,  attribute 
little  importance  to  it,  but  Hofmeier  in  an  analysis  of  Schroeder's 
operation,  has  demonstrated  its  influence  (out  .of  twenty-one  oper- 
ations without  opening,  U\o  deaths ;  out  of  fifty-nine  with  opening, 
eighteen  deaths).  It  is  important,  then,  to  reduce  this  danger  to  a 
minimum,  partly  by  assuring  rapid  cicatrization  by  exact  coap- 
tation, partly  by  energetic  treatment  of  the  mucous  membrane  in  the 
neighborhood  of  the  wound.  To  this  end,  Olshausen  has  advised 
scooping  the  base  of  the  wound  out  to  a  funnel-shape,  by  dissecting 
and  removing  as  much  of  the  mucosa  as  possible.  It  is  also  neces- 
sary to  cauterize  the  base  of  the  wound  with  a  strong  solution  of 
carbolic  acid  (10-100),  or  better,  with  Paquelin's  thermo-cautery, 
which  one  should  not  fear  to  sink  deeply  and  peri^endicularly  in 
the  cervical  canal.  The  cautery  should  not  be  carried  on  the 
suprficial  parts  of  the  wound,  so  as  to  compromise  the  primary 
union  that  is  so  carefully  sought. 

The  suture  is  then  proceeded  with.     Veit  and  Martin  employ  only 


178 


Treatment  of  Fibroid  Tumora. 


juniper  catgiit.  Schroeder  and  Hofnieier  combine  the  use  of  catgut 
and  silk.  If  there  is  a  raw  siu-face  of  but  little  extent,  it  is  sufficient 
to  pass  with  a  strong  needle  some  sutures  buried  deeply  under  all 
the  wound  and  forming  a  series  of  separate  stitches  wMeh  are  strongly 
tied.  The  coaptation  of  the  peritonseuni  is  completed  by  some 
superficial  stitches.  It  is  very  necessary  not  to  lose  sight  of  the  fact 
that  an  exact  coaptation  is  indispensable  for  primary  union.  The 
difficulty  is  to  suture  sufficiently  to  obtain  tliis  and  yet  not  enough 
to  compromise  the  nutrition  of  the  tissues.  If  the  wound  be  of 
considerable  extent  tins  simjjle  means  must  be  renounced  for,  to 
obtain  perfect  coaptation,  we  w^ould  have  to  tie  the  deep  sutures 
too  tight.  To  avoid  this  recourse  is  had  to  the  continued  sutui-e  of 
catgut  in  superposed  row^s,  as  preferable  to  the  interrupted  suture 
of  silk  that  Schroeder  first  employed.  However,  to  guard  against 
too  rapid  absorption  of  the  catgut,  especially  to  be  feared  if  the  tissues 
are  very  resisting,  care  should  be  taken,  before  beginning  the  con- 
tinued suture,  to  place  some  sustaining  stitches  of  silk  passed  under 
the  whole  thickness  of  the  woiuid.  They  are  tied  only  after  having 
completed  the  continued  sutui-e.  It  is  better  to  place  them  in  advance 
and  avoid  the  danger  of  cutting  the  other  sutures  with  the  needle. 
They  should  be  placed  a  little  on  the  Inas  and  not  entirely  perpen- 
dicular to  the  axis  of  the  wound  (Hofmeier),  in  such  a  way  that  they 
wiU  not  be  parallel  to  the  vessels  that  they  are  intended  to  constrict 
(Fig.  80).  The  wound  should  be  reunited  longitudinally,  that  is, 
parallel  to  the  abdominal  wound. 


Fig.  8o. — Suiure  of  pedicle  in  the  intraperitoneal  method  (Schroeder).     S,  deep  suture 
of  silk  ;  C,  continued  suture  of  catgut  in  superposed  rows :  P,  peritonaeal  covering. 

When  the  pedicle  has  been  sutured  according  to  Schroeder's 
method  and  when- after  removal  of  the  elastic  cord  drops  of  blood 


Treatment  of  Fibroid  Tumors. 


179 


ooze  from  the  surface  along  the  sutures,  Martm  does  not  hesitate  to 
traverse  the  pedicle  from  before  backward  with  a  strong  needle 
furnished  with  a  quadruple  tlu'ead  and  to  ligate  in  two  halves.  In 
the  autopsies  that  he  has  made  he  has  never  seen  a  trace  of  mortifi- 
cation in  consequence  of  this  ligature.  Leopold  often  employs  the 
same  procedure  of  supplementary  ligature. 


Fig.  8i  — Vaginal  drainage,  wuh  cross  shaped  tube,  after 
vaginal  hysterectomy  (Martin) 

Martin  always  practices  drainage  after  intravaginal  hysterectomy, 
however  simple  the  operation  may  have  been.  He  depresses 
Douglas'  cul-de-sac  with  one  hand  introduced  through  the  abdomen 
behind  the  uterus  and  with  a  long  forceps  holding  the  cruciform 
drainage-tube,  he  iiierees  the  vagina  from  below  upward.  The 
inferior  extremity  of  the  tube  in  the  vagina  is  always  surrounded 
by  antiseptic  gauze.  The  tube  is  withdrawn  about  the  third  or 
fourth  day,  when  the  patient  begins  to  feel  a  certain  peculiar 
uneasiness  in  the  lower  abdomen  (Fig.  81).  This  drainage,  after 
simple  operations,  \\ithout  ragged  edges  or  infection  of  the  peri- 
tonaeum by  septic  products,  is  not  generally  employed. 

Extra-peritonceal  method. — The  abdominal  cavity  is  kept  closed 
above  the  tumor  as  much  as  possible  and  the  growth  is  surrounded 
with  compress-sponges  to  soak  up  the  blood.  The  section  of  the 
pedicle  is  then  made  transversely  at  two  finger's  breadth  above  the 
elastic  Hgature.  At  this  moment  there  are  sometimes  seen  on  the 
cut  surface  some  fibrous  nuclei  which  penetrate  into  the  pedicle. 
They  can  be  enucleated  without  danger  of  haemorrhage.     If  vessels 


180 


Treatment  of  Fibroid  Tumors, 


are  seen  they  are  ligatecl  separately.  The  surface  of  the  stump  Is 
trimmed  and  it  is  strongly  drawn  outward  with  a  volsella.  The 
toilet  of  the  peritouteum  comes  next  and  then  the  pedicle  is  to  be 
fixed  in  the  lower  part  of  the  wound.  The  provisional  elastic 
ligature  can  often  he  used  as  a  permanent  Hgature  if  it  is  con- 
veniently placed.  If  it  is  situated  so  low  that  it  cannot  be  easily 
drawn  outside  the  wound,  a  new  hgature  may  be  placed  above  the 
first  before  loosening  this.  When  the  pedicle  is  very  thick  it  is 
useful,  according  to  Hegar,  to  tie  it  in  two  halves  after  having 
transfixed  it  with  a  double  elastic  cord  by  the  use  of  Kaltenbach's 
needle.  I  believe  this  complication  can  be  avoided  by  placing  an 
extra  turn  of  the  elastic  cord  on  these  large  pedicles.  Great  care 
must  be  taken,  in  applying  the  permanent  hgature,  not  to  include 
any  organ,  bladder,  intestine  or  omentum.  In  order  to  do  this, 
touch  should  always  be  controlled  Ijy  vision. 


Fig.  82. — Suture  of  the  abdominal  walls  about  the  pedicle  in 
supravaginal  hysterectomy.     Extra-peritonseal  method. 

The  permanent  ligature  is  placed  as  follows :  "WTiUe  an  assistant 
holds  the  pedicle  in  place  mtli  the  forceps,  the  ligator  which  holds 
the  elastic  cord  is  given  two  turns  so  as  to  cross  the  ends  of  the 
hgature  and  tighten  them  a  little,  and  at  the  place  of  crossing, 
between  the  instrument  and  the  cerA-ix,  a  hgature  of  strong  silk  is 
applied  and  tied  with  a  surgeon's  knot.  A  slight  traction  is  again 
given  to  the  instrument  in  such  a  way  as  to  tighten  the  elastic  cord 
a  little  more  and  to  leave  room  to  place  a  second  ligature  for  safety 
some  millimeters  in  front  of  the  first.  Finally  the  ends  of  the  silk 
thi-ead  are  cut,  leaving  them  a  little  longer  than  those  of  the  elastic 
ligature,  after  having  removed  the  forceps  of  the  ligator.  The 
elastic  is  an  immense  improvement  on  the  ordinary  ligature.     Its 


Treatment  of  Fibroid  Tumors.  181 

constriction,  always  active,  so  to  speak,  is  maintained  by  the  virtue 
of  the  elasticity  of  the  cord  which  has  been  strongly  stretched  from 
the  moment  of  its  application.  It  is  not  exposed  to  relaxation,  to 
sagging,  like  unyielding  thi-eads. 

One  of  the  most  important  peculiarities  of  Hegar's  procedure  is 
the  perfect  isolation  of  the  pedicle  outside  the  abdominal  cavity  by 
the  suture  of  the  peritonaeum  under  the  elastic  ligature.  Hegar 
constructs  thus  the  base  of  a  peri-pedicular  space,  that  he  leaves 
open  by  the  non-union,  in  the  immediate  vicinity  of  the  pedicle,  of 
the  aponeurotic,  adipose  and  tegumentary  planes.  Tliis  fossa 
prevents  narrow  imprisonment  of  the  pedicle  in  the  thickness  of 
the  soft  parts  and  their  infection  by  its  subsequent  mortification. 
It  remains  isolated,  like  a  pistil  in  the  center  of  the  calyx  of  a 
flower,  and  can  be  surrounded  by  topical  applications  intended  to 
keep  it  aseptic  and  to  mummify  it.  It  is  especially  in  fleshy  women 
that  this  particular  technique  is  of  great  interest. 


Fig.  83. — Suture  of  the  abdominal  walls  about  the  pedicle  in 
supravaginal  hysterectomy.     Extra-peritonseal  method. 

For  the  suture  of  the  peritonseum  around  the  pedicle,  Tauffer  fixes 
by  a  knot  a  long  tliread  with  two  ends  at  the  inferior  angle  of  the 
abdominal  incision.  Each  of  these  ends  is  armed  with  a  needle. 
These  are  used  to  sew  the  peritonaeum  to  the  surface  of  the  pedicle 
immediately  under  the  ligature,  to  the  right  and  to  the  left.  For 
myself,  I  prefer  to  make  an  overcasting  of  catgut  with  a  single 
needle  (Figs.  82  and  88).  It  is  necessary  to  do  this  with  great  care, 
uniting  a  collar  of  peritonaeum  immediately  under  the  elastic 
ligature.  Only  the  serous  membrane  should  be  comprised  in  this 
suture  and  a  very  fine  curved  needle  should   be  used   to  avoid 


182  Treatment  of  Fibroid  Tumors. 

bleeding  points  if  possible.  It  is  useful  in  this  peripeduncular 
suture  to  seize  the  stumps  of  the  broad  ligaments  and  bring  them 
close  to  the  pedicle  in  such  a  way  as  to  fix  them  in  immediate 
contact  with  the  uterine  stump.  When  the  peritoneal  collar  is 
fixed  around  the  pedicle  the  same  needleful  of  catgut  can  be  used 
to  continue  the  isolated  suture  of  the  peritonaeum  to  the  whole 
length  of  the  abdominal  incision  (Fig.  13).  There  are  added,  if 
needed,  some  separate  stitches  to  complete  the  coaptation. 

The  suture  of  the  other  planes  of  the  abdominal  walls  is  only 
commenced  at  two  finger's  breadth  above  the  pedicle  (Fig.  15). 
Above  the  pedicle  itself  it  is  usually  well  to  place  one  or  two  more 
stitches.  To  prevent  the  pedicle  from  descending  too  far  into  the 
pelvis,  under  the  elasticity  of  the  tissues,  movements,  etc.,  it  is 
transfixed  above  the  elastic  ligature  by  two  strong  pins,  disposed 
in  an  X,  cutting  their  points  immediately  after.  These  pins  have 
the  advantage  also  of  impeding  the  slipping  of  the  elastic  ligature. 
Under  their  extremities  are  placed  small  rolls  of  iodoform  gauze 
to  avoid  wounding  the  integument.  With  the  scissors  the  pedicle 
is  then  given  its  final  shape,  and  its  surface  is  cauterized  after 
having  surrounded  it  with  moist  antiseptic  compresses. 

Until  lately  Hegar,  Kaltenbach,  Tauffer,  etc.,  made  finally  the 
following  dressing :  In  the  peripeduncular  space  there  is  placed 
absorbent  cotton,  soaked  in  the  chloride  of  zinc  (10-100)  and  care- 
fully squeezed  out.  The  surface  of  the  stump  is  painted  with  a 
solution  of  50-100,  and  in  the  center  of  the  pedicle,  in  the  cavity 
that  it  presents,  is  placed  a  tampon  of  cotton  soaked  in  the  same 
caustic.  After  an  antiseptic  dressing  (iodoform  gauze)  it  is  covered 
with  thick  layers  of  cotton-wool  held  in  place  by  a  flannel  bandage. 
This  first  dressing  is  left  in  place  five  to  seven  days,  except  on 
special  indications.  The  stump  is  then  found  hard  and  dry.  The 
tampons  around  the  pedicle  are  replaced  \sith  strips  of  iodoform 
gauze  and  the  stump  is  touched  anew  with  the  caustic  solution  to 
mummify  the  eschar  and  prevent  it  from  becoming  soft  and  fetid. 
From  this  time  the  dressings  are  renewed  every  day  and  if  the  stump 
is  very  large  the  gangrenous  portions  are  removed  little  by  little. 

More  recently  Kaltenbach  has  replaced  the  chloride  of  zinc 
(which  has  the  inconvenience  of  producing  too  extensive  eschai-s 
and  exposing  to  capillary  hemorrhages)  Avith  a  thin  dressing  of 
iodoform  gauze.  But  in  very  anaemic  and  in  very  fat  subjects,  when 
the  peripeduncular  space  is  very  deep,  absorption  occurs  quickly 
and  gives  rise  to  sj^mptoms  of  poisoning.  Kaltenbach  has  there- 
fore employed  a  mixture  of  three  parts  of  tannin  with  one  part  of 
salicylic  acid,  recommended  by  Freund,  in  the  operation  for  extra- 
uterine pregnancy.  He  obtains  the  best  results  with  it,  and  Hegar 
also.     I  have  replaced  the  salicylic  acid  with  powdered  iodoform  in 


Treatment  of  Fibroid  Tumors.  183 

the  proportion  of  one  to  five  of  tannin.     I  lia^e  only  praise  for  this 
mixture. 

The  dressings  are  thus  often  very  simple.  Immediately  after 
the  operation,  the  peripeduncular  space  is  filled  and  the  pedicle 
covered  with  the  powder  (after  a  previous  cauterization  with  the 
thermo-cautery),  then  the  dressings  are  placed.  In  this  way  the 
pedicle  has  the  henefit  of  the  tannic  acid  without  fear  of  cauterizing 
the  living  parts.  This  first  dressing  can  be  left  from  eight  to  ten 
days.  This  modification  constitutes  a  very  great  advance.  It  leaves 
the  patient  undisturbed  in  place  of  fatiguing  her  with  repeated 
dressings.  Finally,  the  mummification  being  obtained  by  a  single 
application  and  as  a  whole,  it  is  not  necessary  to  cut  away  the  stump 
from  time  to  time  with  the  scissors,  a  procedure  which  by  disturb- 
ing it  may  cause  small  pulmonary  emboli  (Kaltenbach). 

On  the  third  or  fourth  day  after  hysterectomy  there  is  often  a 
slight  bloody  flow  from  the  vagina.  It  has  no  serious  significance. 
The  elastic  ligature  generally  falls  off  on  the  fifteenth  or  twentieth 
day,  bringing  with  it  the  pedicle  and  pins.  There  remains  a  granu- 
lating cavity  that  is  dressed  with  iodoform  gauze  lightly  packed  in. 
It  often  presents  a  considerable  depth,  for  it  is  rare  that  necrosis 
of  the  pedicle  is  arrested  at  the  level  of  the  ligature,  it  generally 
passes  this  limit  more  or  less.  The  cicatrix  creates  a  weak  point 
in  the  abdominal  wall  and  necessitates  the  use  of  a  belt.  If  the 
ovaries  have  been  left  in  place,  a  hsemorrhage  may  appear  from 
the  cicatrix  at  each  monthly  period.  An  abdomino-cervical  fistula 
has  been  found  to  persist  at  this  point  in  rare  cases. 

Vaiious  procedures. — Although  he  was  anticipated  to  some  extent 
by  Czerny  and  by  Kaltenbach,  Olshausen  was  the  one  Avho  especially 
recommended  dropping  the  elastic  ligature  into  the  abdominal 
cavity.  He  first  tied,  then  sutured  it  around  the  pedicle  to  prevent 
slipping.  This  procedure  has  been  employed  by  Olshausen  only  in 
exceptional  cases,  such  as  those  where  the  haemostasis  presented 
gi-eat  difficulties.  The  pedicle  thus  tied  did  not  slough,  but  received  ■ 
a  little  nourishment,  either  passing  beneath  the  ligature  or  coming 
from  the  contiguous  parts.  However  that  may  be,  its  nutrition  is 
very  insignificant  and  it  undergoes  a  granulo-fatty  necrobiosis. 
There  were,  besides,  some  cases  where  it  suppurated  and  caused 
gi'ave  symptoms  terminating  either  in  escape  of  the  ligature  (Hegar) 
or  in  fatal  peritonitis  (Olshausen,  Czerny,  Hegar).  At  other  times 
the  elastic  cord  has  been  cast  off  without  danger  to  the  patient. 
Ahlfeld  cites  a  remarkable  case  where  this  mode  of  ligature  was  made 
still  more  complicated  by  fixing  the  rubber  cord  with  a  lead  ring  five 
millimetres  in  diameter.  After  passing  the  ligature  twice  around 
the  pedicle  the  ring  was  crushed  on  it  with  a  strong  forceps.  Tliis 
mode   of  fixation   of  the   elastic  ligature  was  first  employed  by 


184 


Treatment  of  Fibroid  Tumors. 


Thiersch,  but  only  for  the  extra-peritonseal  treatment.  It  has  also 
been  imitated  by  Sanger,  who  abandoned  it  later  for  his  mixed 
method,  after  having  obtained  nine  successes  without  a  single  failure. 


Fig.  84. — Ligature  of  the  pedicle  by  Zweifel's  method  (schematic).  A,  transfixion 
of  the  pedicle  by  a  needle  armed  with  the  first  thread  /a  lb :  B,  the  extremity,  lb,  of 
the  first  thread  being  drawn  out  of  the  eye  of  the  needle,  a  second  thread  Ila  lib 
is  introduced,  after  which  the  needle  is  drawn  back;  C,  the  needle  armed  with  the 
second  thread  transfixes  the  pedicle  anew,  a  finger's  breadth  from  the  first  puncture. 
The  same  procedure  will  place  the  third  thread,  etc.;  D,  a  series  of  threads  disposed 
as  they  are  to  be  tied. 

I  cite  the  f  ollomng  procedures  only  on  account  of  their  originality : 
Swarz  originated  a  method  consisting  in  covering  the  elastic  ligature 


Treatment  of  Fibroid  Tumors. 


185 


with  a  slip  of  the  peritoneum  cut  from  the  pedicle  after  provisional 
hsemostasis.  The  pedicle  was  then  left  in  the  abdomen.  Meinert 
has  proposed  to  open  Douglas'  cul-de-sac  and  invert  the  pedicle  into 
the  vagina.  He  resorted  to  this  procedure  once ;  the  patient  died. 
I  simply  mention  hysterectomy  in  two  stages,  the  first  consisting  in 
opening  the  peritonaeum,  followed  by  the  production  of  adhesions ; 
the  second  stage  relating  to  the  extraction  of  the  myoma.  Nussbaum 
employed  this  dangerous  procedure  in  a  case  of  suppurating 
myoma ;  the  patient  died.  Vulliet  has  recently  tried  to  make  use 
of  this  method :  his  patient  had  not  yet  recovered  at  the  date  of  this 
publication. 


Fig.  85. — Suture  of  the  pedicle  by  Zweifel's  method.     Suture  of  the  broad 
ligaments  and  placing  the  provisional  elastic  ligature. 

Partial  juxtaposed  ligatures. — Under  this  name  Zweifel  has  de- 
scribed a  procedure  of  suturing  the  stump  which  certainly  ensures 
better  hsemostasis  than  that  of  Schroeder,  but  which  appears  a 
priori  a  step  behind  it  in  technique,  from  the  point  of  view  of 
primary  union,  and  its  chances  of  mortification.  However,  the 
good  results  announced  by  Zweifel  challenge  attention.  Out  of  ten 
cases  operated  by  this  method,  he  had  only  a  single  death  at  the 
time  of  publication  of  liis  book  (1888),  and  in  1889  he  announced  a 
new  series  of  twenty-two  operations  followed  by  recovery.  His 
technique  is  as  follows :  He  uses  aseptic  silk  for  all  his  ligatures 
and  employs  a  strong  needle  with  a  blunt  extremity.  He  first 
ligates  the  broad  ligaments  by  a  series  of  partial  sutures.  The 
ligaments  are  then  divided  and  an  elastic  cord  applied.  Care  is 
taken  to  leave  long  ends  to  the  silk  ligatures  of  the  broad  ligaments 


186 


Treatment  of  Fibroid  Tumors. 


that  are  nearest  to  the  uteraa,  and  iu  placing  the  elastic  cord  these 
ends  are  brought  up  under  it  (Fig.  85).  The  uterine  tumor  is 
excised  iu  such  a  way  as  to  produce  a  small  musculo-peritonasal 
flap  iu  front  and  behind  (Fig.  86).  The  uterine  and  cei-vical  cavities 
are  cauterized  with  the  thermo-cautery.  A  number  of  partial 
ligatures,  forming  a  continuous  series,  are  then  placed  as  indicated 
in  the  illustration  (Fig.  84).  Suture  of  the  stump  is  completed  with 
some  superficial  catgut  stitches  of  the  peritonieum  (Fig.  87).  There 
is  no  drainage  unless  there  is  a  persistent  oozing,  when  drainage 
is  made  thi-ough  the  vagina  with  the  cruciform  tube. 


Fig.  S6. — Ligature  of  the  pedicle  by  Zweifel's  procedure. 

Mixed  method. — This  originated  from  the  impossibihty  that  some 
surgeons  found  of  fixing  too  short  pedicles  outside  the  abdominal 
walls,  while  they  dared  not,  however,  drop  them  back  into  the 
abdomen.  Such  was  the  case  of  Kleeberg  who  brought  a  short  and 
thick  pedicle  to  the  bottom  of  the  abdominal  wound,  fastening  it 
by  bringing  the  extremities  of  the  elastic  ligature  outside.  Pean 
also  has  had  analogous  cases.  But  these  were  cases  of  necessity. 
The  fixation  of  the  pedicle  immediately  under  or  in  the  thickness 
of  the  abdominal  walls,  with  persistence  at  this  point  of  a  communi- 
cation with  the  exterior,  has  recently  been  proposed  as  an  operation 
of  choice.  It  permits  a  watch  over  those  cases  where  hsmostasis 
has  been  difficult  and  provides  an  outlet  for  products  which  might 
infect  the  peritouieum.  Wolfler  and  von  Hacker,  of  A'ienua,  and 
Sanger,  of  Leipzig,  have  proposed  mixed  methods  that  are  worthy 
of  description  in  detail. 


Treatment  of  Fibroid  Tumors. 


187 


The  Wolfier-Hacker    method. — The   pedicle   is 
sutured  according  to  Sehroeder'c  method,  then  it 
is  allowed  to  descend  so  that  its  summit  is  at  the 
level  of  the  deep  surface  of  the  abdominal  wall. 
To  fix  it  in  this  place,  against  the  incision  in  the 
pai-ietal  peritoneum,  a  needle  threaded  with  car- 
bolized  silk  is  passed  to  the  right  and  to  the  left, 
traversing  the  superficial  layers  of  the  pedicle, 
then  the  abdominal  walls.    These  loops  of  thread 
are  tied  over  small  rolls  of  iodoform  gauze  in 
such  a  way  as  to  draw  the  surface  of  the  stump 
between  the  lips  of  the  peritoneal  wound.     At 
this  place  the  wound  is  left  open,  and  the  parietal 
peritonaeum  sutured  to  the  stump  so  that  the  of  pedicle  by  Zweifel's 
abdominal  cavity  is  closed  above  it,  and  that  it  "^'  °  ' 
becomes  truly  extra-peritonaeal  and  at  the  same  time  juxta-parietal. 
The  abdominal  walls  are  sutured,  leaving  only  the  place  necessary 
for  the  passage  of  a  roll  of  iodoform  gauze  and  of  a  drainage  tube 
■which  is  insinuated  as  far  as  the  pedicle  (Figs.  88  and  89). 


Fig.  87.  —  Ligature 


Fig.  88. — Treatment  of  the  pedicle  by  the  mixed  method  (Wolfler-Hackler 
procedure).     Schematic  median  section. 

Although  this  method  may  not  be  brought  into  constant  use,  it  is 
certainly  a  very  useful  procedure  to  understand.  It  is  applicable 
to  a  very  short  and  thick  pedicle,  that  cannot  be  drawn  between  the 
lips  of  the  abdominal  wound  without  excessive  traction,  and  where 
the  abundance  of  the  vessels  and  the  number  of  ligatures  appear  to 
make  it  dangerous  to  drop  it  into  the  abdominal  cavity  from  fear 
of  secondary  haemorrhage. 


188 


Treatment  of  Fibroid  Tiimort 


Fig.  89. — Treatment  of  the  pedicle  by  the  mixed 
method  (Wolfler-Hacker  methodj. 

Sanger's  method  consists  iu  sutuiing  the  parietal  peritonseum 
closely  to  the  pedicle,  fixuig  it  along  the  posterior  surface  of  the 
uterine  stump.  The  ahdominal  cavity  is  thus  separated  from  the 
space  in  -which  the  pedicle  is  sequestered.  Sanger  distinguishes 
two  classes  of  cases:  1.  Pedicle  treated  by  sutui-es  according  to 
Schroeder's  method,  hut  from  "nhich  hsemoiThage  is  f eai'ed.  It  may 
be  fixed  under  the  abdominal  -wall  by  suturmg  it  to  the  parietal 
peritoujeum.  Drainage  is  establisded  at  this  point  (Fig.  90).  2. 
Pedicle  too  short  to  be  drawn  out ;  pins  placed  at  a  distance  from 
the  elastic  hgatiu-e,  disposed  as  for  treatment  by  Hegar's  method. 
In  this  last  case  the  peritonaeum  is  sutm-ed  to  the  upper  part  of  the 
pedicle  even  in  front  of  the  elastic  cord,  so  as  to  isolate  it  outside 
the  peritoufeum.  A  sort  of  barrier  is  formed  above  it.  Attempt 
is  thus  made  at  an  extra-peritonsal  elastic  hgature,  although  inti'a- 
abdominal.  Sanger  had  good  success  with  this  method  in  a  difficult 
case  where  the  stump  was  short,  thick  and  very  vascular  (Fig.  91). 


Fig.  90. — Treatment  of  the  pedicle  by  the  mixed 
method  (Sanger's  method). 

If  these  two  procedures  of  Sanger  are  carefully  examined  it  v,i\l 


Treatment  of  Fibroid  Tumors. 


189 


be  seen,  in  fact,  that  the  first  does  not  differ  essentially  from  that 
of  Wolfier-Hacker.  With  regard  to  the  second,  it  is  the  Hegar's 
method  applied  to  a  short  pedicle  where  the  peripeduncular  suture 
is  replaced  by  a  supra-peduncular  suture  of  the  peritonaeum.  It  has, 
however,  this  original  point,  that  the  peritonaeum  is  sutured  (with 
catgut)  above  the  elastic  ligature  and  consequently  on  the  parts 
that  will  mortify.  Sanger  finally  powders  the  stump  with  a  mixture 
of  salicylic  acid,  iodoform  and  tannin.  To  this  I  add  a  tampon  of 
iodoform  gauze. 


Fig,  91. — Treatment  of  the  pedicle  by  the  mixed 
method  (Sanger's  method). 


Extripation  of  the  ])edicle  or  total  hysterectomy. — Bardenheuer  has 
recommended  this  as  a  procedure  of  choice  even  in  the  most  simple 
cases.  He  advises  final  inversion  toward  the  vagina  of  the  broad 
ligaments  on  which  are  placed  solid  ligatures.  He  considers  the 
establishment  of  drainage  essential.  Total  hysterectomy  may  be 
attempted  in  cases  where  the  infiltration  of  the  cervix  by  the  fibroma 
makes  the  conservation  of  a  pedicle  appear  impossible.  However, 
a  pedicle  can  always  be  made  by  enucleating  and  emptying  the 
stump  and  applying  on  the  shell  an  elastic  ligature.  This  may  be 
left  in  the  abdomen  or  treated  by  the  mixed  method  if  the  stump  is 
too  short  to  be  brought  outside.  The  methods  of  Olshausen  and  of 
Sanger  appear  to  be  less  formidable  than  total  extirpation,  although 
Bardenheuer  has  had  from  the  beginning  six  successful  operations 


190  Treatment  of  Fibroid  Tumors. 

out  of  seven.  But  it  appears  that  these  were  simple  cases  that  should 
have  done  well  under  any  method.  Lately  Martin  is  advising 
total  hysterectomy.  He  first  makes  supravaginal  hysterectomy 
through  the  abdomen,  after  provisional  elastic  ligature.  Then  an 
assistant  frees  the  cer^•is  thi'ough  the  vagina,  after  which  the  surgeon 
terminates  the  operation  through  the  abdomen  Ijy  ligatiug  the 
broad  ligaments  and  detaching  the  bladder.  Maiiin  recommends 
protecting  the  intestines  by  a  sponge  soaked  in  an  aseptic  oil, 
believing  that  this  is  unfavorable  to  the  development  of  adhesions. 

IV.  Intra-Ugamentous  and  pelvic  fibroids. — From  a  sm'gieal  point 
of  view  these  varieties  are  united  in  one  group,  by  the  extreme 
difficulty  of  constricting  a  pedicle  and  their  intimate  and  extended 
relations  with  the  walls  of  the  pelvis  and  with  the  pehic  %'iscera. 
The  sugieal  treatment  of  these  tumors  presents  many  difficulties. 
It  may  be  necessary  after  opening  the  abdomen,  if  they  appear  so 
great  that  extii-pation  offers  no  real  chances  of  success,  to  have 
recourse  to  castration  (palliative)  in  the  place  of  ablation  (curative). 
It  must  be  gi-anted,  however,  since  it  is  not  iTsually  the  hiemorrhages 
but  the  pressure  effects  that  are  to  be  feared  in  this  class  of  cases, 
that  castration  is  of  doubtful  value  ;  it  should  only  be  performed  as 
a  last  resort. 

I  propose  to  give  the  name  decortication  to  the  procedure  which 
consists  in  extracting  these  tumors  from  their  celliilar  bed,  reserving 
the  term  enucleation  for  the  extraction  of  fibroids  from  the  uterine 
tissue.  The  common  use  of  the  same  word  for  two  so  different 
operations  often  gives  rise  to  confusion. 

It  is  absolutely  impossible  to  give  a  regular  and  typical  deseiiption 
where  the  cases  depart  so  much  from  all  rules  and  are  atypical. 
The  application  of  a  provisional  elastic  ligature  wiU  be  only  rarely 
possible.  Care  is  here  redoubled  not  to  iuclude  the  bladder,  as  it  is 
generally  much  elongated  on  the  anterior  surface  of  the  uterus.  If 
a  portion  of  the  fibroid  projects  largely  into  the  peritonaeal  cavity, 
the  ligature  will  be  placed  as  deeply  as  possible  on  the  base  of  this 
lobe,  and  it  may  be  removed  without  fear.  Attempt  is  made  to 
enucleate  the  deeper  parts  by  exercising  strong  traction.  The  elastic 
ligature  foUows  the  slu-inking  jof  the  tumor  and  always  makes  a 
sufficient  liiTpmostatic  constriction  of  the  shell  that  has  been  emptied. 
More  frequently  it  is  necessary  to  commence  the  operation  by  the 
ligature  and  section  of  the  appendages  of  the  side  operated  on.  If 
possible  in  the  begimiing  to  place  a  deep  ligature  on  the  trunk  of  the 
uterine  artery,  this  should  not  be  neglected. 

In  some  cases  these  procedures  may  be  impossible  and  it  may 
be  necessary  to  come  at  once  to  the  fundamental  stage  of  the 
operation,  to  the  opening  of  the  ligamentous  surroundings  of  the 
tumor.  This  done  the  Ups  of  the  incision  are  grasped  in  the  forceps 
and  the  decortication  of  the  tumor  is  made  with  the  fingers  or  a 


Treatment  of  Fibroid  Tvmors. 


191 


spatula.  Strong  tractions  will  be  made  with  the  volsella,  turning 
out  the  tumor  as  perfectly  as  possible,  while  on  the  bleeding  points 
forceps  are  placed,  taking  care  not  to  lose  sight  of  the  ureters. 
Once  the  fibroid  is  removed  the  large  veins  of  the  broad  ligaments 
are  spontaneously  closed  and  fewer  ligatures  may  be  needed  than 
was  expected. 

The  connections  of  the  tumor  with  the  uterus  determine  the  pro- 
cedures with  regard  to  that  organ.  When  they  kie  of  but  limited 
extent  the  necessary  ligatures  or  sutures  are  made  at  these  points, 
leaving  the  uterine  body  in  situ.  But  if  they  are  intimate  or 
hsemostasis  is  difficult,  it  is  better  to  decide  without  hesitation 
upon  supravaginal  hysterectomy.  It  may  also  happen  that,  at  the 
end  of  a  laborious  decortication  of  a  fibroid  filling  the  whole  pelvis, 
we  arrive  at  last  at  a  pedicle  which  is  at  once  recognized  as  the 
cervix  uteri  itself.  It  only  remains  to  treat  the  cavity  resulting 
from  the  decortication,  a  cavity  which  is  often  large  and  which  has 
diverticula  behind  the  rectum  and  bladder  or  on  the  sides  of  the 
vagina.    One  or  the  other  of  the  two  following  plans  will  be  adopted  : 

If  there  is  full  confidence  in  the  asepticism  of  the  operation, 
immediate  union  is  attempted  without  drainage.  If  there  are  no 
tears  or  ragged  edges  to  the  peritonaeum,  as  in  some  operations  for 
relatively  small  tumors,  or  of  loose  connections,  we  may  confine 
ourselves  to  placing  some  sutures  to  reunite  the  divided  parts,  to 
making  the  toilet  of  the  peritonaeum  and  to  closing  the  abdomen. 
If  the  pocket  is  very  deep  and  vascular,  a  continued  suture  in 
superposed  rows  can  be  made,  both  for  the  purposes  of  reunion  and 
hsemostasis.  We  do  not  hesitate  to  excise  the  debris  that  would  be 
exposed  to  sloughing. 


Fig.  92. — Intra-ligamentous  fibroid.     A.   Horizontal  section 
B.  Suture  of  the  pocket  after  enucleation  (Kaltenbach). 

But  this  course  will  be  justifiable  only  in  exceptional  cases.  If 
the  cavity  be  of  considerable  extent  (Fig.  92)  and  if  oozing  be  feared 
drainage  will  be  prudent.  This  can  be  made  in  two  ways :  Martin 
recommends  drainage  tlrrough  the  vagina  with  the  cruciform  tube 
introduced  by  incising  the  cul-de-sac  (Fig.  93).     Kaltenbach  has 


192 


Treatment  of  Fibroid  Tumors. 


adopted  the  same  method.  Sanger,  after  having  dropped  a  pedicle 
into  the  abdomen,  was  obliged  to  open  the  cavitj-  thi-ough  the  vagina 
and  tampon  the  sac  of  the  tumor. 


Fig.  93 


-Intra-ligamentous  fibroid.     Decortication  and  suture  of  the  pocket 
and  vaginal  drainage  (Martin). 


Drainage  by  the  inferior  portion  of  the  abdominal  wound  vrill  be 
preferable  in  some  eases  according  to  the  situation  of  the  pocket. 
It  offers  the  certain  advantage  of  less  exposure  to  infection.  Terrier 
has  recently  treated  in  this  way  a  large  pocket  left  by  a  myoma  of 
the  broad  ligament ;  there  resulted  a  fistula.  Howard  A.  Kelly  has 
left  open  and  drained  the  cavity  resulting  from  the  enucleation  of 
a  pelvic  fibroid  compromising  the  bladder,  which  he  fortunately 
decorticated.  He  used  carbolized  injections  thi-ough  the  di'ainage 
tube,  the  ca^vity  of  the  peritonaeum  being  separated  from  the  first 
days  by  protecting  adhesions.  For  myself,  I  prefer  to  use  both 
as  a  means  of  ha?mostasis  and  as  capillary  drainage,  tamponne- 
meut  with  iodoform  gauze.  I  have  irsed  this  A^-ith  success  in  a  case 
of  intra-Ugamentous  fibroid  which  weighed  fifteen  pounds.  Tauft'er 
has  obtained  smgular  success  with  partial  resection  of  large  intra- 
ligamentous fibroids,  fixing  the  stump  in  the  abdominal  wound  and 
treating  it  with  energetic  cauterizations  of  zinc  chloride. 

Accidents. — Haemorrhage  formerly  constituted  one  of  the  dangers 
that  was  most  feared  and  numbers  of  patients  have  died  on  the 
operating  table  fi-om  this  cause.  To-day  it  can  be  avoided  by  the 
judicious  use  of  the  temporary  ela'stic  ligature.     It  should  be  noted 


Treatment  of  Fibroid  Tumors.  193 

that  this  does  not  contemplate  here,  as  in  Esniarch's  bandage  of 
the  limbs,  the  production  of  ischsemia  of  the  tumor.  The  operator 
should  not  be  surprised,  on  incising  the  uterus  above  the  constrict- 
ing cord,  to  see  quite  a  flow  of  residual  blood,  which  was  imprisoned 
at  the  time  of  the  ligature.  If  there  is  a  telangiectasic  tumor,  or 
if  the  broad  ligaments  contain  dilated  veins,  these  ligaments  must 
be  ligated  with  great  care,  being  divided  only  between  two  ligatures. 
The 'ligatures  must  be  passed  with  blunt  needles  to  avoid  wounding 
the  vessels.  For  greater  rapidity,  these  ligatures  can  often  be 
replaced  by  the  application  of  long  forceps.  In  excising  the  tumor 
above  the  elastic  ligature  care  should  be  taken  not  to  carry  the 
knife  too  near  this  cord,  to  avoid  escape  of  the  pedicle  from  its 
control  in  any  portion  of  its  circumference. 

Extra-peritonseal  treatment  with  the  elastic  ligature  of  the  pedicle 
completely  avoids  secondary  hasmorrhage.  The  same  cannot  be 
said  of  intra-peritonseal  treatment  with  ligature  of  the  stump 
with  silk  or  catgiat.  It  must  be  remembered  that  the  uterine 
arteries  should  then  be  tied  with  a  very  light  mediate  ligature 
placed  to  the  right  and  to  the  left  of  the  pedicle,  witlia  strong  needle 
taking  up  a  considerable  thickness  of  tissue.  In  spite  of  this  pre- 
caution fatal  hiemorrhage  has  often  been  noted  some  hours  and 
even  some  days  after  the  operation,  in  consequence  of  slu'inking  of 
the  tissues  and  loosenmg  of  the  ligatures. 

The  possibility  of  wounding  the  bladder  should  always  be  taken 
into  consideration.  If  this  organ  is  elongated  in  front  of  the  tumor 
ft  must  be  detached  to  an  extent  sufficient  to  permit  it  to  be  pushed 
outside  the  elastic  cord.  In  even  extensive  wounds  of  the  bladder, 
attempt  should  be  made  to  place  an  immediate  continued  suture 
of  catgut  in  two  or  tln-ee  superposed  rows.  Catgut  is  preferable  to 
silk  in  extra-peritonasal  treatment  of  the  pedicle,  on  account  of  the 
danger  of  infection  of  the  silk  by  secretions  from  the  peripeduncular 
wound.  On  the  contrary  silk  should  be  used  if  the  pedicle  is  left 
in  the  abdomen.  A  soft  catheter  furnished  with  a  tube  forming  a 
syphon  may  be  kept  in  the  bladder  for  ten  days.  Sanger  has  used 
a  different  method,  imposed  by  circumstances,  in  a  case  where  the 
elongated  bladder  was  included  by  sutures  in  the  pedicle  of  an 
ovarian  tumor.  He  closed  the  peritonaeum  perfectly  around  the 
vesical  pedicle  by  a  method  of  isolation  analogous  to  that  which  he 
employs  for  the  uterine  pedicle.  The  patient  recovered  without 
fistula. 

The  urachus  has  remained  pervious  after  being  divided  during 
an  operation  and  has  thus  caused  fistula  in  rai-e  cases.  It  has, 
however,  a  tendency  to  spontaneous  closure  (Atlee,  Sanger).  It  is 
better,  however,  to  guard  against  this  accident  by  carrying  the 
abdominal  incision  outside  the  cord,  where  it  is  encountered.  If 
wounded,  it  should  be  attached  to  the  thickness  of  the  abdominal 


194  Treatment  of  Fibroid  Tumors. 

wall  by  deep  sutures  (Spencer  Wells).  The  patient  should  be 
carefully  catheterized  every  three  hours  after  the  operation  to  avoid 
distention  of  the  bladder. 

I  believe  that  ligature  of  the  ureter  has  often  been  made  during 
haemostasis  of  the  stump,  and  that  more  than  one  death  has  been 
attributed  to  shock,  when  it  was  due  to  this. 

The  intestine  may  be  simply  applied  to  the  surface  of  the  fibrous 
tumor  and  can  then  be  easily  separated  with  the  fingers.  But  it 
may  also  be  fused  with  a  tumor  that  derives  nutrient  vessels  from 
it.  I  have  observed  this  fact  in  a  large  subperitonaeal  fibroid.  It 
is  then  necessary  to  leave  a  thin  layer  of  the  tumor  adherent  to  the 
intestine  by  detaching  it  by  careful  dissection.  This  fibrous  flap, 
if  it  is  not  too  extensive  can  be  doubled  on  itself  and  sutured 
(Fig.  78).  If,  on  the  contrary,  a  large  surface  of  the  intestine  is 
thus  laid  bare,  there  is  a  risk  of  narrowing  its  calibre  by  a  similar 
coaptation  of  the  raw  siu-f  ace.  It  is  better  in  this  case  to  touch  this 
surface  lightly  \vith  the  thermo-cautery,  and  then  to  fix  it  by  catgut 
sutures  to  the  parietal  peritoneum,  as  near  as  possible  to  the 
abdominal  wound  if  drained.  Simply  dropping  it  into  the  abdomen 
will  expose  to  adhesions  and  possible  ileus. 

Causes  of  death  after  abdominal  hysterectomy. — The  haemorrhage,  the 
septicaemia  and  the  complex  sjTnptoms  designated  by  the  term 
shock,  are  the  three  gi-eat  causes  of  death  after  this  operation.  Less 
frequent  causes  are  embolism,  ileus  and  tetanus. 

I  have  akeady  spoken  of  primary  haemorrhages.  When  the 
pedicle  is  retui-ned  to  the  abdomen  after  Schi-oeder's  method, 
secondary  haemorrhage  is  always  to  be  feared.  We  are  warned  of 
this  by  the  excessive  agitation  of  the  patient,  the  acceleration  and 
softness  of  the  pulse,  the  swelling  of  the  abdomen,  and  the  paleness 
of  the  face  and  mucous  membranes.  Some  patients  have  had  a 
very  distinct  sensation  of  a  hot  jet  flowing  in  the  abdomen.  In 
other  cases  the  bloodv'  serum  has  been  seen  to  ooze  thi-ough  the 
external  sutures  of  the  abdominal  wall.  The  blood  may  also  be 
effused  in  great  abundance  under  the  peritoneum,  between  the 
broad  ligaments,  and  form  an  enormous  retro-peritonaeal  haemato- 
cele,  or,  again  it  may  accumulate  in  the  pocket  left  by  a  tumor 
enucleated  from  the  pelvic  celliilar  tissue,  and  then  protrude  into 
the  ecchymosed  vagina.  If  internal  haemorrhage  is  suspected,  the 
abdomen  must  be  opened  at  once  to  ligate  the  vessels  and  to  remove 
the  liquid  and  clots.  Besides,  if  the  state  of  the  circulation  per- 
mits, if  the  force  of  the  heart  is  not  too  much  compromised,  there 
should  be  injected  into  the  cephalic  vein  about  a  litre  of  sterilized 
water  at  38°  C,  containing  chloride  of  sodium,  6-1000.  If  the 
pulse  is  so  feeble  that  it  appears  dangerous  to  suddenly  increase 
the  contents  of  the  vessels,  an  injection  will  preferably  be  made  into 


Treatment  of  Fibroid  Tumoi's.  19-5 

the  subcutaneous  cellular  tissue,  in  small  quantities  at  a  time,  of 
one  hundred  to  two  hundred  grammes  of  a  saline  solution. 

Septicaemia  may  be  produced  in  different  ways.  It  may  proceed 
from  operative  faults,  from  insufficient  antisepsis  or  asepsis.  But 
the  most  frequent  cause  is  certainly  the  infection  of  the  peritonaeum 
by  germs  from  without  through  a  pedicle  left  in  the  abdominal  cavity. 
From  this  arises  the  necessity  for  the  precautions  recommended, 
of  destroying  the  mucosa,  and  of  vigorous  coaptation  of  the  surfaces 
to  obtain  a  perfect  occlusion.  The  constriction  of  the  sutures  is 
evidently  not  sufficient  to  explain  the  mortification  of  the  pedicle 
when  sutured  and  dropped  into  the  abdomen.  It  is  known,  that 
when  beyond  the  action  of  germs  the  tissues  deprived  of  circulation 
only  undergo  a  granulo-fatty  degeneration.  Besides,  circulation 
may  be  re-established  by  adhesions,  or  even  by  bridges  of  tissue 
thrown  above  the  ligature  wliich  is  thus  encapsulated  little  by  little. 
The  action  of  germs  is  indispensable.  There  exist  some  obser- 
vations on  late  or  secondary  infection  of  the  sutures  of  the  intra- 
peritonseal  stump,  that  are  of  interest  in  connection  with  the  use  of 
silk  sutures  or  to  elastic  ligature.  The  infection  may  then  come 
by  the  tubes  or  even  through  the  intestines,  in  consequence  of  a 
temporary  coprostasis.  Finally,  a  latent  microbism  may  be  in- 
invoked  in  some  cases. 

Under  the  term  shock  has  been  comprised  an  assemblage  of 
symptoms  of  depression  from  various  causes,  from  which  death 
ensues  after  grave  or  prolonged  operations.  No  doubt  a  great 
number  of  these  cases  may  be  attributed  to  haemorrhage.  Others 
may  be  only  due  to  an  acute  uraemia  arising,  either  from  accidental 
ligature  of  the  ureter,  or  to  complete  abolition  of  the  action  of  the 
kidneys,  when  these  organs  were  already  diseased,  under  the 
influence  of  traumatism  and  the  absorption  of  the  anaesthetic. 
Finally,  degeneration  of  the  heart  may  be  looked  to  in  a  number 
of  cases.  Against  shock  should  be  advised,  first,  among  women 
whose  circulation  is  bad,  the  mixed  method  of  anaesthesia  with 
preliminary  injection  of  atropine  and  morpliine.  I  would  recom- 
mend also  a  rapid  operation.  Care  should  also  be  taken  to  protect 
the  intestines  fi-om  the  air  by  the  use  of  the  hot  compress-sponges. 
Ordinarily  a  very  small  opening  in  the  abdomen  ■\^^R  be  made.  To 
combat  the  phenomena  of  extreme  depression,  we  have  the  use  of 
hot  frictions,  hypodermic  injections  of  ether,  alternated  every 
quarter  hour  with  injections  of  caffeine.  If  it  is  supposed  that 
acute  anaemia  plays  a  pari  in  the  symptoms,  an  injection  may  be 
given  under  the  skin,  in  the  subclavicular  region,  of  one  hundred  to 
two  hundred  grammes  of  a  sterilized  saline  solution  (6-1000). 

Embolism  has  caused  death  in  some  cases,  even  in  convalescence. 
Absolute  repose  cannot  be  insisted  on  too  much,  especially  if  the 


196  Treatment  of  Fibroid  Tumors. 

tumor  was  Tery  vascular  or  the  broad  ligameuts  were  varicose. 
Intestinal  occlusion  has  been  observed  after  hysterectomy,  as  after 
all  abdominal  operations.  But  it  should  be  noted  that  some  cases 
published  under  this  heading  were  only  pseudo  strangulations  due 
to  intestinal  paralysis,  showing  the  existence  of  an  unrecognized 
infectious  peritonitis.  To  prevent  any  chance  of  this  terrible 
complication  one  should  be  sparing  of  antiseptics  in  the  peritouseal 
cavity  if  he  use  them  at  all  there.  These  substances  act  with  an 
extreme  intensity  on  the  delicate  epithelium  of  the  serous  membrane 
and  predispose  to  plastic  exudates.  Care  also  should  be  taken  not 
to  leave  any  raw  surfaces  in  the  abdomen.  The  section  of  the 
stump  should  be  covered  by  the  peritonaeum  carefully  sutiu-ed. 
Sutures  of  catgut  should  close  the  broad  ligaments  when  divided 
or  lacerated  in  the  process  of  decortication.  In  the  treatment  of 
ileus,  before  reopening  the  abdomen,  trial  should  be  given  the 
method  praised  by  Bode  and  Leopold,  which  consists  in  forced 
enemas  of  a  hot  infusion  of  chamomile,  with  the  addition  of  soap 
and  on,  then  turning  the  patient  on  the  side. 

Gravity  of  hysterotomy.  —  Comparison  of  the  results  of  different 
methods. — It  is  exceedingly  difficult  to  establish  the  actual  gi-avity 
of  the  operation  from  statistics,  the  majority  of  authors  taking  no 
care  to  divide  their  observations  into  comparable  categories.  Thus 
a  t j'pical  supravaginal  amputation  cannot  be  made  to  figure  by  the 
side  of  decortication  of  large  pelvic  fibroids.  There  is  more  dif- 
ference between  these  operations  than  between  an  amputation  of 
the  leg  and  an  amputation  of  the  thigh.  For  want  of  better,  how- 
ever, it  is  necessary  to  have  recourse  to  what  statistics  we  have. 
I  present  the  most  recent,  for  it  is  evident  that  no  account  should 
be  taken  of  the  older  data,  when  the  technique  was  incomplete  and 
the  antisepsis  insufficient.  The  first  series  is  taken  from  Paul 
Wehmer : 

A. — INTHA-PEKITON^AL  METHOD. 


Numbe: 

r  of  Operations 

Deaths. 

Mortality  per  100. 

Gusserow, 

19 

6 

316 

Kaltenbach, 

s 

3 

60.0 

Martin, 

S6 

15 

17-4 

Olshausen, 

29 

9 

31.0 

Spencer  Welli 

>, 

26 

10 

38.0 

Schroeder, 

135 

41 

300 

Tauffer, 

12 

4 

33-0 

Bantock, 

22 

Hegar, 

22 

Kaltenbach, 

22 

Keith, 

3S 

Pean, 

52 

Tauffer, 

17 

Spencer  Wells, 

20 

-EXTEA-PERITON.EAL  METHOD. 

Deaths.  Mortality  per  100. 

2  9.0 

6  27.0 

1  4.5 

2  S-3 
iS  340 

2  11.7 

10  50.0 


Treatment  of  Fibroid  Tumors. 


197 


Lawson  Tait, 
Thornton, 


37-0 
13.0 


262                        63  24.0 

Zweifel  has  collected  a  still  more  recent  series  from  among  the 
German  surgeons  alone : 

A. — EXTKA-VERITON^AL  METHOD. 

Number  of  Operations.      Deaths. 

Carl  Braun  von  Femwald,  from  1880  to  1887,  63  12 

Fehling,                                                                  15  1 

Gusserow,                                                                 3  3 

Kehrer,                                                                     9  2 

Leopold,                                                                 14  3 

Saxinger,                                                                10  3 

Schauta,                                                                    5  2 

Schultze,                                                                   I  I 

Werth,                                                                      2  I 

Zweifel,                                                                    8  I 

130  29 
B. — INTRA-PEEITONiEAL  METHOD. 


Number  of  Operations. 

Deat 

Carl  Braun  von  Femwald, 

5 

2 

Dohrn, 

9 

0 

Fehling, 

3 

2 

Gusserow, 

23 

6 

Kehrer, 

3 

2 

Leopold, 

19 

7 

Range, 

II 

4 

Saxinger, 

7 

6 

Schauta, 

I 

I 

Schultze, 

12 

3 

Werth, 

II 

Winckel, 

2 

I 

Zweifel, 

10 

I 

116  38 

In  this  series  the  mortality  for  the  extra-peritonseal  method  is 
22.3  per  100,  and,  even  excluding  Braun's  exceptional  resmts,  it 
remains  at  only  25.3  per  100.  The  mortahty  for  the  intra- 
peritonaeal  method  is  32.7  per  100.  The  relative  benignity  of  the 
fii'st  method  is  apparent  from  these  figures.  An  objection  has  been 
raised  to  these  statistics.  It  has  been  remarked  that  in  the  pre- 
ceeding  lists  the  avowed  partisans  of  the  extra-peritonseal  treatment 
(Kaltenbach,  Thornton,  S.  Keith)  are  also  among  the  operators  by  the 
intra-peritonaeal  method.  Evidently  their  cases  were  not  similar  in 
the  two  series,  and  those  where  they  left  the  pedicle  in  the  abdomen 
were  more  serious  than  those  to  which  they  applied  their  favorite 
treatment.  It  is  better,  then,  to  take  the  number  of  surgeons 
exclusively  practicing  the  intra-peritonaeal  treatment  of  the  pedicle. 
Here  is  the  list  extracted  from  the  preceding : 


Numbe: 

r  of  Operations. 

Deaths. 

Mortality. 

A.  Martin, 

86 

IS 

17.4 

Olshausen, 

29 

9 

31.0 

Schroeder, 

136 

41 

30.1 

Gusserow, 

23 

6 

26.0 

Schultze, 

12 

3 

25.0 

198  Treatment  of  Fibroid  Tuin<rrs. 


Werth, 

11 

3 

27.2 

Dohrn, 

9 

o 

0.0 

Leopold, 

19 

7 

36.8 

Runge, 

II 

4 

36.3 

Zweifel.* 

10 

I 

lO.O 

The  mortality  falls  in  this  list  to  'lo.b  per  cent.  But  if  a  similar 
analysis  of  the  series  operated  hy  the  extra-peritonaeal  method, 
and  the  cases  of  Schultze  and  Werth,  noted  partisans  of  the  oppo- 
site method  are  taken  out,  the  mortality  falls  to  21.6  per  100. 
The  extra-peritona;al  method  still  has  the  advantage.  Its  superi- 
ority is  also  eonfii'med  by  the  latest  statistics.  Tautfer,  out  of 
tifty-one  hysterectomies,  has  had  twelve  deaths,  being  22.0  per 
100  (extra-peritonseal  hysterectomies).  Fritsch,  in  the  operations 
where  he  employed  the  extra-peritonaeal  treatment  of  the  pedicle 
(slightly  modified  intra-parietal  procedui-e,  analogous  to  that  of 
WoMer-Hacker),  had  only  five  deaths  out  of  twenty-thi'ee,  while  he 
had  had  before  eleven  deaths  oiit  of  twenty-seven  with  Schi-oeder's 
intra-peritonaeal  method.  Albert,  from  thirty  operations,  had  only 
one  death  by  the  extra-peritoneal  method. 

C.  Braun,  in  his  last  series  of  thirty-eight  hysterectomies  with 
extra-peritonaeal  treatment,  lost  only  six,  being  15.5  per  100. 
Finally  Hegar  has  reported  his  last  series,  extending  from  .June, 
1887,  to  May,  1889,  to  Nicaise.  It  comprises  besides  two  myo- 
mectomies for  pedunculated  fibroids,  cured,  eighteen  supravaginal 
hysterectomies  for  interstitial  fibroids,  all  followed  by  cure,  and 
twelve  hysterectomies  for  intra-ligamentary  tumors,  with  only  two 
deaths  (one  at  the  end  of  four  months,  the  other  five  mouths). 

It  is  necessary,  however,  to  recognize  the  disadvantages  and 
dangers  of  each  of  those  methods.  The  presence  in  the  center  of 
the  abdominal  wound  of  a  gangrenous  pedicle  constitutes,  in  the 
first  place,  a  striking  disadvantage  of  the  exti-a-peritonseal  method, 
although  the  use  of  the  new  pulverulent  dressing  adopted  by  Kalten- 
bach  very  much  diminishes  the  harm  which  may  result  from  the 
mortification  of  the  pedicle.  Moreover,  recovery  is  slower  and  a 
weak  point  is  left  in  the  abdominal  wall.  These  disadvantages  are 
compensated  l)y  the  gi'eater  security,  the  perfect  hfemostasis  by  the 
constriction  of  the  elastic  ligature,  the  external  drainage  of  the 
secretions  from  the  pedicle,  removing  the  double  fear  of  internal 
hfemorrliage  and  peritonaeal  infection  which  always  exists  when  the 
pedicle  is  left  in  the  abdomen,  especially  if  the  uterine  cavity  has 
been  opened.  The  solution  of  the  problem  does  not  lie  in  the  abso- 
lute excliTsion  of  one  or  the  other  method,  it  lies  rather  in  a  reason- 
able choice  between  the  two  in  individual  cases. 

What  are  the  dangers  to  be  feared  in  the  intra-periton»al  method '? 
They  are,  the  extreme  vascularity  rendering  hsmostasis  impossible 

*  Since  the  exclusive  adoption  of  the  partial  juxtaposed  intra-peritonxal  ligature,  first 
series  of  operations. 


Treatment  of  Fibroid  Tumors. 


199 


uterine  cavity). 


Very  vascular  pedicle. 


No  pedicle:   easily  enucleated  in- 
terstitial or  submucous  tumors. 


without  multiple  sutures,  in  themselves  exposing  to  necroses  and  to 
septicaemia ;  the  opening  of  the  uterine  cavity,  giving  access  to  germs 
from  the  vagina ;  in  a  word,  the  danger  lies  in  bleeding  pedicles  and 
in  Jiollow  pedicles. 

The  following  table  states  in  brief  the  principles  which  guide  me 
to  a  choice  among  these  operations  : 

Slightly  bleeding  and  simple  pedi-   f  Ligatures    or   sutures   of    silk   and    catgut    and 
cles  (without  opening  into  the  -j  abandonment    in    the    peritonaeal    cavity 

uterine  cavity).  [  (Schroeder's  method). 

„,.,,,,      ,.  J  .    „  ,.     fA.  Sufficient  length:    extra-peritonaeal  (Hegars 

Slightly  bleeding  and  hollow  pedi-  method) 

.^!!!:  1'^^''^.:.°'?'^"'"^    *"'°    "'''   I  B.   Insufficient  length  :  mixed  treatment  (WolHer- 
^  Hacker  or  Sanger's  method). 

A.  Sufficient  length :  extra-peritoneal  treatment 
(Hegar's  method). 

B.  Insufficient  length :  mixed  treatment,  with 
elastic  ligature  (Sanger's  method). 

C.  Very  short:  intra- peritonseal  treatment,  with 
the  elastic  ligature  left  in  the  abdomen 
(Olshausen's  method)  or  total  hysterectomy 
(Bardenheuer's  method). 

'A.  Lateral  portions  of  the  uterus  (very  vascular): 
supravaginal  hysterectomy  and  extra- 
peritonaeal  treatment  (Hegar's  method), 

B.  Posterior  or  anterior  face  of  the  uterus  (little 
vascularity) :  enucleation,  suture  of  the 
capsule  and  intra-peritonEeal  abandonment 
(Martin's  method). 

C.  Idem,  with  opening  of  the  uterine  cavity  during 
enucleation :     supravaginal   hysterectomy, 

[  extra-periton£eal  treatment  (Hegar). 

f  A.  Small  tumor,  easily  enucleated :  decortication, 

I  total  suture  of  the  pocket,  no  drainage. 

B.  Large  tumor  easily  detached  from  the  uterus, 
large  cavity  or  bleeding  pocket:  decorti- 
I  cation,   partial    resection    and    superficial 

suture  of  the  pocket  and  drainage  by  the 
vagina  (Martin),  or  drainage  through  the 
abdominal  wound,  according  to  the  case; 
if  necessary,  tamponnement  with  iodoform 
gauze.  Uterus  respected. 
C.  Idem,  with  narrow  and  vascular  connections 
with  a  lateral  portion  of  the  uterus:  supra- 
vaginal hysterectomy  (for  treatment  of  the 
pedicle,  see  above).  Suture  and  drainage 
of  pocket  with  or  without  tamponnement. 


No  pedicle:  tumors  fixed  in  the  | 
pelvic  cellular  tissue  or  in-  - 
eluded  in  the  broad  ligament 


200  Castration  of  Fibroid  Tumors. 


CHAPTER  XII. 


CASTRATION   OF   FIBROID   TUMORS. 

Clinical  experience  long  since  taught  that  the  cessation  of  sexual 
life  in  woman  produced  in  most  cases  a  remarkable  relief  from 
the  symptoms  caiised  by  fibroid  tumors.  The  haemorrhage  ceases 
and  the  tumor  itself  often  diminishes  and  atrophies.  From  this 
arose  the  idea  of  treatment  artificially  inducing  the  menopause  by 
ablation  of  the  ovaries. 

It  is  not  easy  to  settle  clearly  the  indications  for  this  operation. 
Hegar  is  almost  disposed  to  advise  it  in  all  cases  in  preference  to 
hysterectomy,  making  the  latter  as  a  secondaiy  operation  of  cas- 
tration is  not  sufficient.  However,  it  is  not  to  be  doubted  that 
there  are  some  cases  where  this  operation  is  dangerous  by  reason 
of  its  sequelae,  even  when  it  is  easy,  and  others  where  it  is  danger- 
ous on  account  of  the  inherent  difficulties  of  its  accomplishment. 
In  the  first  class  of  castrations  are  very  large  fibro-cystic  or  solid 
tumors.  It  is  then  to  be  feared  that  castration,  by  obliteration  of 
the  arterial  vessels,  veins  and  lymphatics,  will  produce  rapid 
changes  of  nutrition  that  are  to  be  feared.  Primary  mortification, 
cedema  and  consecutive  thi-omboses  and  embolisms  are  possible 
when  the  tumor  and  the  broad  hgaments  contain  large  bloodvessels. 
Again,  castration  may  be  a  primarily  dangerous  operation,  where 
it  is  difficult  on  account  of  very  vascular  adhesions  or  the  complete 
obliteration  of  the  mugs  of  the  broad  Ugament,  as  in  some  intra- 
ligamentous tumors ;  immediate  haemorrhage  is  then  to  be  feared. 
It  is  convenient  to  place  these  considerations  in  the  first  rank,  for 
they  dominate  the  operative  indications.  They  can,  perhaps,  be 
briefly  stated  thus  :  Whenever  castration  would  be  less  dangerous 
than  hysterectomy,  and  when  the  latter  is  not  formally  indicated 
by  the  symptoms  of  pressure,  the  former  should  be  preferred. 

Hysterotomies  for  pedunculated  fibroids  are  preferable  to  cas- 
trasion  for  two  reasons  :  fii'st,  because  they  are  relatively  of  little 
gravity ;  second,  because  in  this  variety  of  fibroid,  haemorrhage  is 
the  least  important  symptom.  Interstitial  fibromata  of  abdomi- 
nal evolution,  small  or  of  medium  volume,  should  be  treated  by 
castration  if  the  only  symptom  they  determine  is  loss  of  blood. 
The  same  is  true  for  the  intra-Ugamentous  and  pelvic  fibroids  at 
the  commencement  of  their  evolution.  The  ansemic  state  of  the 
patients  will  also  be  a  special  indication  for  ablation  of  the  ovaries 
in  preference  to  that  of  the  uterus.   But  it  is  impossible  to  formulate 


Castration  of  Fibroid  Ttmiars.  ■    201 

indications  and  contra-indieations  in  a  definite  manner  before 
opening  the  abdomen.  Exact  account  can  then  be  taken  of  the 
relations  of  the  tumor  and  the  amount  of  danger  involved  in  the 
different  procedures. 

Operative  technique. — The  most  favorable  time  for  this  operation 
is  the  week  following  the  menstrual  period.  The  preparations  for 
the  operation,  the  rules  for  opening  the  abdomen,  are  the  same  as 
in  all  laparotomies.  Hegar  expressly  recommends  palpation  of  the 
ovaries  to  ascertain  their  exact  position  before  opening  the  ab- 
domen. This  is  a  very  useful  precaution,  but  not  always  possible. 
There  are  three  ways  of  arriving  at  the  ovaries  :  the  median  line, 
the  lateral  part  of  the  abdomen,  the  posterior  vaginal  cul-de-sac. 
The  first  alone  is  selected  in  the  vast  majority  of  castrations  for 
myomas. 

First  stage. — Operation  in  the  median  line;  Opening  the  abdomen. 
— The  incision  is  made  below  the  umbilicus  at  a  height  corre- 
sponding to  that  to  which  it  is  supposed  the  fibroid  has  carried  the 
appendages.  At  first  the  incision  should  not  exceed  eight  centi- 
metres, sufficient  to  admit  two  or  three  fingers.  The  peritonfsum 
is  quickly  reached,  placing  forceps  on  vessels  of  any  importance. 
On  arriving  at  the  peritonaeum,  a  fold  of  that  membrane  is  care- 
fully incised,  and  into  the  small  opening  thus  made  a  grooved 
director  is  passed.  By  cutting  on  this  director  wounds  of  the 
intestine  or  of  the  easilj'-bleeding  surface  of  the  tumor  are  avoided. 
The  incision  being  very  small  and  exposed  to  dragging  during  the 
operation  it  will  be  useful  to  immediately  pass  some  loops  of  sutures 
intended  to  provisionally  unite  the  serosa  to  the  abdominal  walls. 
-  These  loops  can  at  the  same  time  be  used  to  open  the  wound. 

Second  stage. — Search  for  the  ovary  and  its  ablation. — A  very  thin 
sponge  is  introduced  through  the  wound  and  serves  to  push  bac< 
the  intestine  and  omentum.  The  index  and  middle  fingers  of  the 
right  hand  are  passed  in  deeply  and  directed  towards  the  fundus  to 
seek  the  ovary,  grasping  it  as  well  as  the  pavillion  of  the  tube 
between  these  two  fingers  and  drawing  it  outside  the  wound.  An 
assistant  immediately  closes  the  lips  of  the  wound.  To  be  certain 
that  the  ovary  is  held  firmly,  the  fingers  are  replaced  by  the  forceps. 
A  blunt  needle  furnished  with  a  double  thi-ead  is  then  passed  through 
the  wing  of  the  ovary  and  tube.  It  is  my  custom  to  tie  the  pedicle 
with  Lawson  Tait's  knot,  as  it  is  expeditious  and  only  leaves  a 
single  knot  in  the  peritonaeum.  But  for  large  pedicles  it  is  neces- 
sary to  tie  with  two  threads.  It  is  rational  and  practical  to  include 
the  tube  in  the  ablation,  especially  as  it  is  usually  the  seat  of 
chronic  inflammation  and  as  its  extirpation  contributes  much  to 
the  disappearance  of  pain  and  haemorrhage. 

If  the  pedicle  is  very  short,  there  can  be  added  to  the  ligature  en 
masse  (which  may  slip)  some  supplementary  ligatures  on  the  vessels. 


202  Castration  of  Fibroid  Tumors. 

In  this  case  it  is  necessary  to  be  positive  that  the  Ugature  has  been 
placed  well  under  the  ovary  and  that  a  portion  of  the  organ  has  not 
escaped.  Then  I  prefer  to  use,  for  certainty,  cauterization  of  the 
pedicle  with  the  thermo-cautery,  destroying  the  tissues  deeply.  If 
there  remains  any  vestige  of  the  ovary  it  will  be  destroyed  or  suf- 
ficiently modified  to  be  absorbed.  The  success  of  the  operation  is 
compromised  by  leaving  the  smallest  portion  of  the  ovary.  I  use 
for  the  caiiterization  an  ordinary,  large,  curved  forceps,  protecting 
the  adjacent  parts  by  a  moist  sponge.  In  place  of  cutting  with  the 
thermo-cautery,  I  divide  the  pedicle  ^ith  the  scissors,  lea\'ing 
above  the  ligature  a  small  stump  of  about  a  half  centimetre  which 
is  shriveled  slowly  with  the  cautery  at  a  dull-red  heat.  This 
cauterization  destroys  the  remains  of  the  ovarian  tissue  and  is  both 
haemostatic  and  antiseptic. 

Whenever  it  is  possible  I  omit  the  use  of  the  forceps.  Seizing 
the  ovary  and  the  tube  with  the  left  hand,  I  divide  thi'ee-quarters 
of  the  pedicle,  with  the  scissors,  at  one  centimetre  above  the  lig- 
ature. Then,  while  the  pedicle  is  held  by  the  part  not  cut,  the 
surface  of  the  divided  portion  is  cauterized,  and  lastly,  the  extreme 
border  of  the  ovary  is  severed  with  the  cautery.  The  ends  of  the 
ligatures  will  be  cut  short,  after  being  assured  that  there  is  no 
oozing  and  that  they  are  well  placed.  Then  the  ablation  of  the 
second  ovary  is  made  in  the  same  manner. 

If  the  incision  is  too  small,  it  is  better  to  enlarge  it  than  to  use 
force.  If  the  intestines  are  an  obstruction,  they  may  be  pushed 
upward  more  easily  if  the  patient's  liips  are  elevated  to  permit  the 
viscera  to  fall  toward  the  diaphragiu.  Tamponnement  of  the  vaguia 
to  elevate  the  organs  above  the  pehis,  or  the  introduction  of  the 
fingers  into  the  vagina  for  the  same  purpose,  \\"ill  rarely  be  neces- 
sary, as  the  organs  are  usually  jpushed  above  their  normal  level  by 
the  tumor.  E^dseration,  or  temporary  extraction  of  the  intestines, 
enveloping  them  in  hot  compresses  gives  more  room,  but  this 
procedure  is  dangerous  and  shoiild  only  be  employed  as  a  last 
resort.  In  no  case  should  the  imprudence  of  bringing  the  fibroid 
tumor  outside  the  abdomen  be  committed,  it  becomes  congested 
and  swollen  and  its  return  is  difficult.  Besides,  it  exposes  to  throm- 
bosis and  embolism.  It  is  better  to  turn  the  tumor  on  its  axis  in 
the  abdomen  to  reach  the  appendages. 

Adhesions  of  the  ovary  and  the  tube  to  contiguous  parts  should 
be  separated  with  gi-eat  care  and  as  much  as  possible  under  the 
eye,  on  account  of  the  considerable  venous  development  which 
sometimes  accompanies  fibroids.  The  shortness  of  the  broad  hg- 
ament  and  in  particular  the  ovarian  wing,  may  constitute  an  insur- 
mountable difficulty.  The  ligatures  slip  and  no  pedicle  can  l)e 
constructed.  In  a  similar  ease  Hegar  terminated  by  hysterectomy 
for  fear  of  losing  his  patient  from  htemorrhage.     Attempt  may  be 


Castration  of  Fibroid  Tumors.  203 

made  to  arrest  the  hfemorrhage  by  a  continiious  suture.  In  some 
cases  an  elastic  ligature  may  be  adjusted  and  left  in  the  abdominal 
cavity. 

Some  surgeons  attribiate  a  very  great  difference  in  castration  to 
ligature  of  the  tubo-ovarian  vessels  without  ablation  of  the  ovary. 
It  acts  either  by  causing  fatty  degeneration  of  the  ovary,  or  by  ■ 
directly  modifying  the  vitality  of  the  uterus  and  the  nutrition  of 
the  neoplasm,  favoring  atrophy.  These  ligatures  should  be  reserved 
for  cases  of  necessity,  where  the  extirpation  of  the  ovaries  offers 
insurmountable  difficulties.  Unilateral  castration  should  rather  be 
founded  on  operative  necessities  than  on  any  theoretical  conceptions, 
and  in  advising  it  Sims  and  Battey  and  their  imitators  have 
evidently  reasoned  from  false  premises.  Extirpation  of  the  ovary 
to  produce  the  menopause  is  rational  only  when  it  is  done  on  both 
sides. 

Thied  stage. — Toilet  of  theperitoiuBum;  Suture. — This  toilet  is 
usually  quickly  performed,  unless  there  has  been  a  rupture  of  a 
cyst  of  tubes  or  broad  ligament.  The  silk  threads  passed  through 
the  abdominal  walls  at  the  beginning  of  the  operation  are  removed 
and  we  proceed  to  continued  suture  of  the  peritoneum  with  catgut, 
then  of  the  musculo-librous  planes.  Sutures  of  the  integument  and 
the  subcutaneous  tissues  are  made  with  interrupted  stitches  of 
strong  silk,  placing  also  some  supplementary  stitches  of  fine  catgut. 
If  the  lips  of  the  wound  have  been  bruised  to  any  extent,  it  is  better 
to  insinuate  a  small  drainage-tube  between  the  sutures  of  the 
muscles  and  those  of  the  skin.  Tins  may  be  withdrawn  at  the  end 
of  twenty-four  hours.  Drainage  of  the  peritonaeal  cavity  may  be 
made  if  there  has  been  an  effusion  of  pus  (pyosalpinx)  into  the 
abdomen,  or  again,  if  the  operation  has  been  exceptionally  long 
and  difficult.  In  the  first  case  an  irrigation  of  the  peritonteum  with 
hot  water  should  be  given. 

After-treatment. — Shortly  after  operation  there  sometimes  occurs 
a  metrorrhagia.  Tliis  should  be  guarded  against  by  hot  vaginal 
injections  and  hypodermics  of  ergotine.  Too  strong  pressure  on 
the  abdomen  should  not  be  used  on  account  of  the  intestmal  paresis 
which  always  follows  a  laparotomy.  The  patient  should  be  given 
an  inclined  position  by  elevating  the  pelvis  to  allow  the  intestines 
to  faU  toward  the  upper  part  of  the  abdomen.  A  laxative  is  given 
the  following  day  to  evacuate  the  gas. 

Prognosis. — Conforming  to  the  method  adopted  I  will  indicate  the 
results  from  the  experience  of  such  surgeons  as  are  accounted  the 
best  authority  on  this  special  subject.  Hegar,  out  of  fifty-five 
operations  had  six  deaths,  or  eleven  per  hundred.  In  a  curative 
point  of  vieAV  Hegar's  cases  are  arranged  as  follows  : 

(a).  Kesults  as  regards  htemorrhage  :  In  twenty  cases,  immediate 
cessation  of  the  hfemorrhage  ;  in  four,  cessation  after  some  irregular 


204  Castration  of  Fibroid  Tumors. 

losses  of  blood;  iu  one,  persistence  of  ii-regular  metrorrhagia;  in 
one,  temporary  menopause,  then  haemorrhage  and  cystic  develop- 
ment of  the  tumor ;  iu  one,  menopause,  then  haemorrhages,  extir- 
pation of  the  tumor. 

(b).  Eesults  as  regard  the  tumor:  iu  twenty-two  cases,  marked 
diminution ;  in  tlu'ee,  no  diminution ;  in  one,  doubtful  diminution ; 
in  one,  development  of  a  fibro-cystic  tumor ;  in  one,  enucleation. 

Tissier  has  collected  a  more  recent  series :  Out  of  one  hundi-ed 
and  seventy-one  operations,  twenty-five  deaths,  a  mortahty  of  14.6 
per  100. 

(a).  Eesults  as  regards  haemorrhage  in  one  hundred  and  forty-six 
collected  cases :  Complete  cessation  in  eighty-nine  eases ;  in 
tweuty-one,  menopause,  after  a  longer  or  shorter  period  of  irregular 
haemorrhages ;  in  ten,  retui-n  of  the  menses  after  a  shoi-t  respite. 
In  this  categoiy  is  found  a  case  of  unilateral  extirpation  and  of  lig- 
atiu'e  of  one  ovary. 

(b).  Eesults  as  regard  the  tumor  (one  hundred  and  forty-six 
cases):  in  nine,  no  change;  in  sixty-six,  rapid  diminution;  in 
seventj'-one,  no  knowledge  of  the  subsequent  condition  (the  patients 
reported  as  cured). 

Lawson  Tait  has  done  castration  for  fibroids  two  hundred  and 
sixty-two  times,  with  a  mortahty  that  he  estimates  at  1.23  per  100. 
These  and  other  figm'es  that  might  be  cited  show  at  once  the  relative 
benignity  of  the  operation  and  its  efficacy  when  it  is  judiciously 
employed.  Those  surgeons  who  still  prefer  hysterectomy  in  all  cases 
are  becoming  less  and  less  numerous. 


Fibroid  Tumors  Complicating  Pregnancy.  205 


CHAPTER  XIII. 


FIBROID   TUMORS   COMPLICATING 
PREGNANCY. 

It  is  known  that  pregnancy  gives  a  very  great  impulse  to  the 
growth  of  fibroids  and  frequently  causes  oedematous  softening. 
These  phenomena  are  the  more  marked  in  proportion  as  the  con- 
nection of  the  tumor  with  the  uterus  is  the  more  intimate,  attaining 
their  maximum  in  interstitial  fibroids,  single  or  multiple,  with 
enormous  thickening  of  the  uterine  tissue,  as  in  cases  which  have 
sometimes  been  improperly  described  under  the  name  of  hypertro- 
phy of  the  uterus.  Tliis  sudden  increase  of  the  size  of  the  tumor 
aggravates  the  pressure  effects  to  which  it  may  already  have  given 
rise  and  the  sufferings  resulting  from  the  pressure  on  the  sacral 
plexus  may  become  intolerable.  It  may  happen  that  retroflexion 
of  the  gravid  and  myomatous  uterus  occasions  symptoms  of 
internal  strangulation.  If  the  tumor  is  in  the  pelvis,  that  is  to  say 
developed  below  the  superior  strait,  originating  in  the  supra- vaginal 
portion  of  the  cervix  or  inferior  part  of  the  body,  accidents  of  com- 
pression are  sudden  and  formidable ;  they  may  relate  to  the  bladder, 
the  ureters,  the  rectum,  the  nerves,  or  the  vessels.  Even  peritonitis 
has  been  noted. 

But  the  most  common  accident,  and  not  the  least  serious  in  such 
cases,  is  abortion.  The  reposition  of  the  uterus  being  prevented, 
the  immediate  danger  of  haemorrhage  is  gi-eat  and  septicsemic  acci- 
dents are  liable  to  occur.  Lefour,  out  of  three  hundred  and  seven 
cases,  has  noted  thirty-nine  abortions  and  death  of  the  mother  four- 
teen times,  Nauss,  out  of  two  hundred  and  forty-one  cases,  has 
noted  forty-seven  abortions. 

Indications  for  treatment  are  drawn  from  the  nature  of  the 
symptoms  and  the  seat  of  the  tumor.  If  we  have  to  do  with  a  sub- 
serous fibroid  (pedunculated  or  sessile)  of  the  fundus  of  the  uterus, 
it  may  be  hoped  that  it  will  not  embaiTass  parturition  in  any  way, 
and  if  there  is  some  danger  of  inflammation  or  cystic  transformation 
of  the  tumor,  there  is  also  some  hope  of  seeing  it  disappear  with 
post-partum  involution.  We  are  able,  then,  to  rely  on  expectation. 
This  appears  more  perilous  in  cases  of  pelvic  fibroids.  However,  if 
they  do  not  cause  serious  symptoms  from  pressure  we  may  wait, 
hoping  that,  at  the  time  of  confinement,  they  may  precede  the  fcetal 
head  in  its  descent  into  the  pelvic  cavity,  or  else  reascend  above  the 


206  Fibroid  Tumors  Complicating  Pregmincy. 

superior  strait  after  the  rupture  of  the  membranes.  Finally,  they 
have  been  seen  flattened,  so  to  speak,  by  the  foetal  head.  All  these 
contingencies  have  been  observed,  and  mth  the  aid  of  forceps  and 
of  version  delivery  is  sometimes  prompt  in  apparently  desperate 
conditions.  Eeduction  of  the  tumor  should  also  be  always  attempted 
in  such  cases  by  pressing  it  back  ■with  the  hand  in  the  vagina.  But 
labor  often  lasts  so  long  that  the  woman  dies  from  exhaustion,  if 
she  does  not  succumb  to  hsemoiThage.  Expectation,  then,  has  limits 
wliich  should  be  passed  the  more  readily  as  the  tumor  is  more 
accessible  and  its  extirpation  presents,  in  consequence,  less  dangers. 
Fibroids  of  the  cervix  belong  to  this  class.  Therefore  their  enucle- 
ation has  often  been  practiced  either  before  or  during  confinement. 
Munde  recommends  enucleation  by  the  vagina  whenever  it  is 
possible.  Even  when  the  operation  is  done  toward  the  close  of 
pregnancy  miscarriage  may  not  result. 

Polypi  may  be  expelled  before  the  foetal  head  and  the  pedicle 
then  torn  off.  It  is  also  easy  to  cut  the  pedicle  to  faciUtate  delivery. 
Fergusson's  mistake  must  not  be  committed.  He  applied  the 
forceps  to  a  large  poljTpus,  belie\'ing  it  to  be  the  foetal  head,  and  the 
patient  succumbed  to  a  rupture  of  the  uterus.  If  the  polji^us  is 
recognized  before  labor,  it  could  be  immediately  extii-pated  were  it 
not  for  the  probable  interruption  of  pregnancy. 

Interstitial  fibroids  of  abdominal  evolution  are  much  more  inac- 
cessible, and  the  operations  necessary  for  their  removal  are  so 
formidable  that  we  may  hesitate  to  undertake  them  and  ask  if 
provoked  abortion  is  not  preferable.  The  temperament  of  the 
surgeon,  his  methods  and  operative  experience  mil  certainly  count 
for  much  in  the  way  he  ■\^ill  solve  this  problem.  He  camiot  conceal 
from  himself  that  provoked  abortion  and  prematm-e  labor  also 
present  serious  dangers.  When  the  placenta  is  inserted  in  the 
region  of  the  tumor,  and  retraction  of  the  uterine  tissue  cannot  take 
place  after  delivery,  a  formidable  haemorrhage  may  occur.  The 
patient  is  also  much  more  exposed  to  puerperal  septicaemia. 
Fui'ther,  as  the  expulsion  of  a  dead  foetus  should  generally  be  pro- 
voked, there  is  here  a  consideration  wliich  ought  to  be  taken  into 
account.  Finally,  abortion  only  slightly  relieves  the  compromised 
organs,  and  if  in  the  end  hysterectomy  must  be  resorted  to,  we 
have  endangered  the  life  of  the  patient  twice  instead  of  once.  Such 
are  the  reasons  for  which  many  surgeons  decide  in  favor  of  early 
interference.  Supravaginal  amputation  is  evidently  preferable  to 
the  Caesarian  operation  which  Cazin  did  with  success  at  the  seventh 
month.  This  author  has  moreover  collected  twenty-eight  cases  of 
Cnesarian  section  necessitated  by  fibroids  of  the  uterus :  only  four 
■women  sundved ;  fifteen  children  ■n-ere  born  li^"ing,  eight  were  dead ; 
there  is  no  information  regarding  the  other  five.     Sanger  has  more 


Fibroid  Tumors  Complicating  Pregnancy. 


207 


recently  collected  a  series  of  forty-three  Caesarian  sections  for 
fibroids ;  only  seven  were  saved,  making  a  mortality  of  83.7  per 
cent.     Tauffer  has  published  one  unsuccessful  case. 

When  hysterectomy  is  decided  upon,  a  partial  operation  (myo- 
mectomy) should  be  attempted,  compatible  ■with  the  continuance  of 
pregnancy,  only  if  the  fibroid  is  pedunculated  or  seated  freely  on 
the  middle  of  the  fundus.  However  slightly  sessile  the  tumor  may 
be  and  however  little,  and  however  limited  the  uterine  lesions  ?  in 
the  region  of  the  cornua,  we  are  exposed  to  considerable  haemor- 
rhages and  to  abortion  under  the  worst  conditions.  Finally,  it  is 
necessary  to  note  that  supravaginal  amputation  (Porro's  operation) 
is  here  made  much  easier  on  account  of  the  laxity  of  the  ligaments 
caused  by  pregnancy. 

The  following  is  a  resume  of  published  results : 


I.— 

-SIMPLE  MYOMECTOMY  ;    THE  UTEEUS  BEING 

SAVED. 

Authors. 

Date  of  Operation 
or  of  Publication, 

Duration 
of  Pregnancy. 

Anatomical  State. 

Result. 

Pean. 

Dec.  15,1874,  C7j«. 
Chir.,  vol.  i.,  p 
679. 

5  months. 

Fibro-cystic  tumor. 

Cured.  Abortion, 
the  day  after  the 
operation. 

Thornton. 

Obst.  Trans.,  June 
4,  1879. 

7  months. 

Pedunculated      tu- 
mor. 

Death  seventh  day. 

Hegar. 

Jan.,  1880,  Opera- 
tive Gyn.,TiAeA., 
P-475- 

3  months. 

Softened,   peduncu- 
lated tumor.  Peri- 
tonitis. 

Death  third  day. 

Schroeder. 

Nov.  16, 1879,  cited 

16  weeks, 

Multiple     peduncu- 

Cured.   Confine- 

hyYiegax, loe.cit. 

lated  tumor. 

ment  normal. 

Studgaard. 

Dec.  19, 1882,  cited 

31^  months. 

Pedunculated      tu- 

Cured.   Pregnancy 

byHegar,/o(r.  «■/. 

mor. 

not  disturbed. 

Martin. 

Berl.  Kl.  Woch, 

6  months. 

Myomectomy,   with 

Death  seventh  day 

1885,  No.  3. 

cuneiform  ex- 
cision of  the  fun- 
dus of  the  uterus 
only. 

from  haemor- 
rhage, following 
abortion. 

Landau. 

Berl.  Kl.  Woch, 

Myoma  the  size  of  a 

Cured.     Confine- 

1885, No.  13. 

child's    head,   on 
the  right;  the  size 
of  an  egg,  on  the 
left. 

ment  normal. 

Ogden. 

Canadian  Prac- 

Not indicated. 

Interstitial     myoma 

Cured.    Abortion 

titioner,  April, 

removed  by  enu- 

twelve   days 

1885. 

cleation.    Preg- 
nancy  not    diag- 
nosticated. 

later. 

Routier. 

Bull.    Soc:   Chir., 
Nov.,  1889. 

3  months. 

Subserous     myoma, 
with  large  base. 

Cured. 

A.  Bergh. 

Hygiea,  1889,  Bd. 

4  months. 

Two     tumors,     the 

Cured.    Confine 

li.,No.  5,  p.  292. 

largest  the  size  01 
two  fists.  Enucle- 
ation. 

ment  normal. 

208  Fibroid  Tumors  Complicating  Pregnancy. 

II. — SUPRAVAGINAL  AMPUTATION  OF  THE  GRAVID  UTERUS. 


Authors. 

Date  of  Operation 
or  of  Publication. 

Duration 
of  Pregnancy. 

Anatomical  State. 

Result. 

Kaltenbach. 

March  2,  I  8  8  o, 
cited  by  Hegar, 
Operation  Gyn., 
3d  ed.,  p.  475. 

5  months. 

Interstitial  myomaof 
the  fundus  of  the 
uterus,  weight 
3500  grammes. 

Cured. 

Wasseige. 

March  i8,  l88o. 

5  months. 

Interstitial  myomaof 
the  fundus  of  the 
uterus,    weight 
4500  grammes. 

Death  sixth  day. 

Nieberding. 

Feb.  10,  1882. 

4  months. 

Death  in  fotty-nine 

hours. 

Schroeder. 

Jan.  lo,  1883. 

3  months. 

Interstitial     myoma 
the     size    of    an 
adult  head. 

Cured. 

Schroeder. 

June  29,  1884. 

3  months. 

Cured. 

Walter. 

Brit.  Med.  Assoc, 
Liverpool,  1SS3. 

4  months. 

Colossal  tumor. 

Death  ninth  day. 

R.  Barnes. 

5/.  George's  Hasp. 
Report, \%T\---j^, 
vol.  viii.,  pp.  91- 
95- 

3  months. 

Fibroid,  concealing 
pregnancy. 

Death. 

Etheridge. 

Am.Jour.ofObsl., 

3months(hav- 

Fibro-cystic  tumor. 

Death   from    peri- 

1887, vol.  XX.,  p. 

ing  tried  in 

tonitis    eleventh 

69. 

vain  to    in 
duce    abor- 
tion). 
4  months. 

day. 

Alex.  Patter- 

Glascnu Med.  J., 

Fibroid,  concealing 

Cured. 

son. 

April,  1885. 

pregnancy. 

Karstrom. 

/^^/<ra,April,i8S7 
and  in  Centr.  f. 
Gyn.,  1887,  No 
34- 

5  months. 

Intra  -  ligamentous 
fibroid       (pedicle 
dropped  and  drain- 
age). 

Cured. 

Freund. 

Observations    u  n  - 
published. 

8  months. 

Fibroid,  concealing 
pregnancy. 

Cured. 

G.  Granville 

Brit.  Gyn.  J.,  vol. 

3  months. 

Fibroid,   concealing 

Cured. 

Bantock. 

H.,  p.  63. 

pregnancy. 

Hofmeier. 

Die    Myomotonne, 
p.  76. 

3  months. 

Fibroid,    with    sus- 
picion    of   preg- 
nancy. 

Cured. 

Disner. 

Centr.  f.   Gyn., 
1887,  p.  119. 

2  months. 

Fibroid.     Foetus 
dead  and  macer- 
ated. 

Cured. 

Kaltenbach. 

Centr.  f.   Gyn., 
1887,  p.  435. 

2  months 

Fibroid  in  process  of 
disintegration  fce- 
tus  macerated. 

Cured. 

D.  von  Ott. 

Archiv.  f.   Gyn., 

9  months. 

Large  fibroid  of  the 

Cured.     Child 

Bd.  xxvii.,p.  88, 

(263  days.) 

supravaginal  por- 

living. 

1890. 

tion  of  the  cervix. 
Intra  -  peritonteal 
treatment  of  pedi- 

A.  Martin. 

N^aturf.     Sainmal. 
Heidelb.      1889, 
(cited  before  the 
Berlin     Soc.    of 
Obst.     Centr.  f. 
Gyn.,  '90,  p.  67. 

4  months. 

cie. 
Tumor   of    the    in- 
ferior part  of  the 
body  of  uterus. 

Cured. 

The  gi'eater  part  of  these  facts  relate  to  operation  before  term. 
If  that  is  waited  for  to  make  a  true  Porro's  operation,  the  prognosis 
is  doubtless  much  gi'aver.  As  important  compensation,  there  is 
the  possibility  of  saving  both  mother  and  child.     It  is  better  not  to 


Cancer  of  the  Cervix  Uteri.  209 

wait  up  to  the  last  day  for  fear  of  being  surprised  by  the  eouimenee- 
ment  of  labor,  but  to  operate  some  days  before  the  supposed  date 
of  confinenieut.  The  procediire  which  appears  then  to  offer  most 
security,  from  the  double  point  of  view  of  haemorrhage  and  septi- 
caemia (both  particularly  to  be  feared  when  a  gi'avid  uterus  is  in 
question)  is  the  extra-peritonasal  elastic  ligature  of  the  pedicle 
(Hegar). 


CHAPTER  XIV. 


CANCER  OF   CERVIX   UTERI— PATHOLOGICAL 

ANATOMY,  SYMPTOMS,  DIAGNOSIS, 

ETIOLOGY. 

Pathological  anatomy. — The  great  predisposition  of  the  cer- 
vix to  malignant  neoplasms  has  attracted  attention  of  all  observers. 
Is  there  any  anatomical  explanation  of  this  fact?  Conheim  has 
suggested  the  theory  that  the  embryonic  cells  (embryo  plastic  cells  of 
Robin),  wliich  have  not  disappeared  in  the  formation  of  the  organs 
and  which  are  found  either  disseminated  in  the  connective  tissue 
or  accumulated  at  certain  points,  constitute  the  fundamental  tissue 
of  carcinoma.  The  seats  of  predilection  for  these  nests  of  embryo 
cells  would  certainly  be  the  natural  orifices,  where  a  more  or  less 
irregular  involution  of  blastodermic  layers  occurs ;  the  cervix, 
developed  relatively  late  at  the  expense  of  Mueller's  tubes,  enters 
into  this  class  of  congenitally  vulnerable  regions.  It  is  also  neces- 
sary to  note  the  presence  of  two  kinds  of  epitheUum  at  the  edge  of 
the  cervical  opening,  and  the  tendency  to  plastic  polymorpliism 
which  may  result  from  it.  The  efficient  cause  of  neoplasm  remains 
to  be  discovered.  Repeated  haemorrhages,  to  which  Conheim 
attributes  so  much  importance,  -will  not  serve  for  sufficient 
explanation. 

In  epithelioma  of  the  mucous  membrane  it  is  evident  that  the 
heterologous  product  provides  the  epithelial  cells,  either  from  the 
net-work  of  Malpiglii  (Klebs),  or  from  the  intra-cervical  cylindi-ical 
ceUs  which  may  project  beyond  the  external  orifice  (Schi'oeder),  or 
from  the  glandular  cells  (Ruge  and  Veit).  In  carcinoma  of  the 
parenchyma,  the  hystogenic  origin  of  the  cells  of  neoplasms  is 
enveloped  in  obscurity.  Virchow  tliinks  they  come  only  from  the 
ceUs  of  the  connective  tissue,  which  agrees  very  well  with  the 
hypothesis  of  Conheim.     The  latest  researches  of  Ruge  and  Veit 


210 


Cancer  of  tJw  Cervix  Uteri. 


support  this  theory.  According  to  them,  cancer  is  most  often  due  to 
a  transformation  of  the  cells  of  the  e(junective  tissue,  even  when  it 
has  the  papillary  form,  as  in  the  caidifioiccr  eccrescencc.  The  Tas- 
ciilar  connective  tissue  returns  to  the  embryonic  state  and  the 
young  cells  take  an  epithelioid  aspect.  In  exceptional  cases,  how- 
ever, they  have  seen  adenoid  vegetations,  produced  hy  glandular 
epithelium,  giving  rise  to  carcinoma. 

Anatomical  forms. — In  a  clinical  point  of  view,  when  cancer 
can  be  observed  at  its  commencement  and  before  its  propagation  to 
neighboring  parts  has  altered  its  primitive  aspect,  four  forms  may 
be  established :  1.  Papillary;  2.  Nodular;  3.  Cancer  of  the  mucosa 
of  the  cervical  cavity  ;  4.  Vaginal. 


Fig.  94. — Cancer  of  the  cervix,  papillary  form. 


1.  Papillary  form. — It  commences  in  that  part  of  the  cervix 
situated  below  the  vaginal  insertion  and  remains  localized  on  its 
surface  for  a  long  time.  The  neoplasm  often  begins  in  the  cylin- 
drical epithelium  which  encroaches  on  the  external  surface  of  the 
cervix.  Thus,  mthout  doubt,  ulceration,  at  first  benign,  is  trans- 
formed into  an  epithelioma.  It  soon  takes  the  papillary  and 
fungoid  appearance,  covering  the  affected  hp  with  a  kind  of  fungus 
which  hides  the  cervical  opening  and  the  healthy  hp.  The  affection 
may  for  a  long  time  evolve  in  situ,-  but  there  comes  a  time  when  it 
attacks  the  vaginal  cul-de-sac,  invades  it  superficiallj-  and  deeply, 
and  from  there  is  propagated  to  the  periuterine  tissues.  More 
rarely  it  is  propagated  in  the  interior  of  the  cervical  canal. 

There  is,  however,  a  concomitant  lesion  of  the  mucosa  of  the 
uterus  which  may  be  very  frequent,  according  to  the  researches  of 
K.  Abel,  who  removed  from  this  the  exclusive  character  which 
Schroeder  gave  it.  Abel,  in  seven  cases  belonging  to  this  class, 
found  sarcomatous  degeneration  of  the  cerdcal  mucosa  in  three 
cases,  and  in  two  other  cases  the  lesions  of  a  doubtful  interstitial 
endometritis,  apparently  in  evolution  toward  sarcoma.     According 


Cancer  of  the  Cervix  Uteri. 


211 


to  this  author,  the  lualign  degeneration  in  always  a  concomitant, 
although  under  different  histological  forms,  in  the  cervix  aiid  in  the 
body.     These  assertions  have  been  strongly  denied  by  others. 

2.  Nodular  form. — It  begins  as  a  nucleus  or  several  nuclei  under 
the  cervical  mucosa,  either  in  its  external  or  in  its  internal  surface, 
only  producing  ulceration  later  on.  Other  nodules  may  exist  at 
some  distance,  even  when  the  lesion  appears  to  be  very  limited.  In 
the  progress  of  the  disease  the  nodule  destroys  the  mucosa  and  con- 
stitutes cancerous  ulceration.  Similar  nuclei,  formed  in  the  cervix 
and  in  the  body  of  the  uterus,  fuse  with  the  first  and  soon  all  the 
organs  and  the  contiguous  tissues  may  be  invaded. 


Fig.  95. — Cancer  of  the  cervix,  nodular 
form.  /,  intact  zone;  /,  cancerous  nod- 
ule ;  a,  OS;  c,  cervix. 


Fig.  96. — Cancer  of  the  cervical  cavity 
at  its  beginning. 


3.  Cancer  of  the  mucosa  of  the  cervical  canal.  —  It  develops  first  in 
the  mucous  membrane  of  the  cervical  cavity,  or  immediately 
beneath,  by  an  infiltration  which  ulcerates  early  and  cause  slow 
destruction  of  the  cervix  by  a  sort  of  erosion.  There  are  some  cases 
where  the  cervix,  devoured  thus  on  its  internal  surface,  has  almost 
disappeared.  It  has  something  analogous  to  the  retraction  of  the 
nipple  in  cancer  of  the  breast.  The  body  of  the  uterus  is  quickly 
attacked  in  tliis  form,  then  the  periuterine  connective  tissue,  and 
the  vagina  last,  or  not  at  all. 

4.  Vacfmal  form. — This  is  infinitely  more  rare  than  the  preceding 
forms.  The  disease  originates  in  the  posterior  cul-de-sac  and 
invades  in  its  progress  the  cervix  and  the  contiguous  portions  of 
the  vagina,  where  it  induces  extended  ulcerations. 

Histological  varieties. — The  three  histological  varieties  that  are 
most  commonly  met  are  :  1.  Pavement  epithelioma,  either  tubular 
orlobulated;  2.  Cylindrical  epithelioma ;  3.  Carcinoma,  or  atypical 
epithelioma.  In  France,  since  the  work  of  Eobin,  of  Lancereaux, 
of  Cornil,  and  of  Malassez,  the  doctrine  of  epithelial  cancer  is  more 
in  favor,  and  carcinoma  itself  is  considered  as  an  alveolar  epitheli- 
oma, a  particular  mode,  an  evolution  stage  of  epithelioma,  and  not 
as  a  neoplasm  primarily  developed  at  the  expense  of  the  cells  of  the 
connective  tissue.     In  connection  with  the  subject  of  diagnosis  I 


212  Cancer  of  the  Cervix  Uteri. 

will  speak  of  a  rare  histological  variety  of  malignant  disease  of  the 
cervix,  sarcoma. 

Pavement  epithelioma,  lobulated  and  tubular,  rarely  occurs. 
Virchow,  however,  has  observed  it.  CyUndi-ieal  epithelioma  is  more 
frequent.  Pavement  epithelioma  is  especially  met  in  the  superficial 
forms  (vaginal  and  papillary).  The  variety  called  lobulated  is 
formed  by  cellular  agglomerations  which  separate  the  fibro-muscular 
bundles.  These  cells  may  have  undergone  colloid  degeneration  or 
form  hard  epidermic  globules.  The  tubular  variety  is  composed  of 
lacunae,  filled  with  epithelial  eeUs,  anastomosing  and  infiltrating 
the  fibro-muscular  spaces.  On  section  there  is  seen  in  the  tubular 
openings  epithelial  cells  deformed  by  pressure. 


-'  c ' 


'.^^m^^mli'i^^^ 


< ,       AiT"    ^ 


Fig.  97. — Cylindrical  epithelioma,  beginning  in  the  superior  portion  of  the  cervix 
and  invading  the  body  (150  diameters),  me,  hypertrophied  uterine  glands;  v. 
vessel;  c,  connective  tissue  (Comil). 

The  cylindrical  epithelioma  usually  coiTesponds  to  the  form  of 
uterine  cancer  which  begins  in  the  cavity  of  the  cervk  and  conse- 
quently resembles  very  much  that  of  the  body  of  the  uterus  (Figs- 
97,  98,  99).  It  begins  with  a  typical  glandular  proliferation  (ade. 
noma),  ending  in  an  atypical  proliferation  (malignant  adenoma, 
which  is  only  epithelioma) .  Cornil  has  insisted  on  the  gi-eat  histo- 
logical resemlilances  between  glandular  metritis  and  certain  stages 
of  the  development  of  cylindrical  epithelioma. 

Atypical  epithelioma,  or  the  carcinoma  of  most  authors,  is  not 
distinguished  very  clearly  from  some  forms  of  tubular  pavement 
epithelioma.  It  is  characterized  by  the  polymorphism  of  its  cells, 
which  recall  neither  those  of  the  mucosa  nor  those  of  the  glands  and 
by  their  disposition  in  agglomerations  in  alveoU  having  walls  formed 
by  the  anastomosing  connective  tissue  bundles  (Fig.  100).  TVTien 
the  fibrous  frame-work  is  lax,  the  cellular  element  predominating 
and  charged  with  juices,  the  tumor  is  called  encephaloid  (Fig.  108) ; 


Cancer  of  the  Cervix.  Uteri. 


213 


if  it  is  hard  and  dry,  it  is  a  scirrhus  cancer.     This  last  variety 
constitutes  the  majority  of  nodular  cancers  (Fig.  95). 


Fjg.  98. — Cylindrical  epithelioma  of  the  body  of  the  uterus  (150  diameters),  cc, 
connective  tissue ;  a,  cavity  filled  with  cells ;  0,  cells  separated  from  the  wall  of  a 
cavity;  f,  cells  undergoing  mucoid  degeneration  (Cornil). 


Fig.  99 — Cylindrical  epithelioma  of  the  body  of  the  uterus  (400  diameters),  b, 
layer  of  cylindrical  cells ;  /5,  cells  undergoing  karyokinesis;  «,  free  cell  undergoing 
degeneration;  i;,  vessel;  rf,  cylindrical  cells  of  a  contiguous  alveolus  (Cornil). 

Secondary  invasions. — At  an  ultimate  period  of  the  disease  cancer 
causes  enormous  lesions  by  its  extension  in  various  directions. 
Extension  to  the  vagina  occurs  very  rapidly  in  the  papillary  form 
and  may  descend  to  the  vulva  (Fig.  101).  The  invasion  of  the  body 
appears  later  in  the  papillary  form,  but  it  should  not  be  forgotten 
that  the  mucosa  here  undergoes,  if  not  a  degeneration  (Abel),  at 


•AU 


Cancer  of  the  Cervix  i'teri. 


Fig.  ioi. — Epithelioma  of  the  cervix,  papillary  form,  invading  the  vagina. 


least  an  intense  inflammatory  proliferation  that  places  it  in  a  state 
of  morbid  imminence,  in  point  of  view  of  propagation.  In  the  form 
attacking  the  cervical  canal  extension  to  the  body  takes  place 
quickly,  it  may  be  at  once  in  the  nodular  form.  Sometimes  in 
examining  a  corpus  uteri  invaded  by  cancer  of  the  cervix  a  very 
clear  line  of  demarkation  is  seen  at  the  edge  of  the  morbid  tissue, 
even  though  there  is  but  very  little  normal  tissue  left.  The  pehac 
connective  tissue  may  be  affected  by  propagation  from  the  vaginal 
cul-de-sac  or  from  the  uterus.  The  organ  is  then  solidly  fixed. 
The  broad  ligaments  are  thickened  and  contracted.  The  vessels 
and  the  nerves  which  traverse  the  cellular  tissue  of  the  pelvis,  and 
especially  the  branches  of  the  sciatic  nerves  are  thus  compressed, 
causing  the  oedema  and  the  intolerable  pains  that  are  observed  in 
the  advanced  stages. 


Cancer  of  the  Cervix  Uteri.  215 


Fig.  I02. — Epithelioma  of  the  cervix,  extending  into  the  body. 


Fig.  103. — Epithelioma  of  the  cervix,  invading  the  Ijody  (encephaloid  variety). 


21(1 


Cancer  of  tlie  Cervix  Uteri. 


The  ureters  are  very  quickly  compromised  by  the  development 
of  cancer.  In  fact,  in  place  of  simply  sinking  do^\Ti  by  its  weight 
as  in  the  case  of  a  fibroid,  the  malignant  neoplasm  assimilates,  so 
to  speak,  the  tissues  from  place  to  jjlace.  Earely  the  wall  of  the 
ureter  ulcerates  and  forms  a  ureteral  fistula.  More  frequently  they 
are  affected  with  stricture.  The  extreme  frequence  of  renal  lesions 
in  cancer  has  been  studied  anew  during  late  years.  Lancereaux 
does  not  hesitate  to  declare  that  an  ascending  nephritis  has  been 
present  in  all  the  autopsies  he  has  made  for  twenty-five  years, 
except  in  some  cases  where  the  fatal  termination  was  premature  in 
consequence  of  haemorrhages.  The  ceUiilar  tissue  wliich  unites  the 
bladder  to  the  cervix  uteri  being  invaded,  the  neoplastic  gro^\i:h 
soon  extends  to  this  organ  and  catai-rhal  inflammation  is  produced. 
Portions  of  the  vesical  mucosa  slough  and  the  morbid  growth  enters 


Fig.  104 — Cancer  of  the  cervix  extending  to  the  vagina 
and  the  bladder,  with  perforation. 

the  bladder,  producing  a  fistula  (Fig.  104) .  Ureteritis  and  septic 
pyelonephi'itis  are  among  the  first  and  the  most  grave  consequences 
of  invasion  of  the  bladder.  This  terminates  in  miliary  abscesses 
of  the  kidney.  This  result,  however,  is  much  rarer  than  nephritis. 
Is  not  the  state  of  the  heart  influenced  by  this  interstitial  nephritis 
and,  in  accordance  Avith  Traube's  theory,  is  there  hypertrophy  of 
the  left  ventricle  ?  Some  autopsies  plainly  demonstrate  this  lesion. 
However,  Lancereaux,  from  observations  on  twenty-thi'ee  cases, 
denies  this.  From  his  important  series  it  is  evident  that  the  cardiac 
lesion  only  exceptionally  accompanies  the  nephritis  of  cancer. 
There  is  also  a  special  form  of  cardiac  lesion,  verrucose  endocar- 


Cancer  of  the  Cervix  Uteri.  217 

ditis,  that  Lancereaux  found  in  two  eases.     It  is  a  special  form  of 
vegetating  endocarditis. 

The  rectum  is  more  rarely  attacked  and  listulse  on  this  side  are 
rare.  The  peritonaeum  is  defended  against  the  invasions  of  the 
growth  by  adhesions  which  separate  its  cavity  from  the  limits  of 
the  disease.  Thus  it  is  that  Douglas'  cul-de-sac  sometimes  appears 
quite  distant  fi-om  the  vaginal  cul-de-sac  when  performing  hyster- 
ectomy. In  very  advanced  cancers  the  rectum  and  bladder  may 
open  into  the  vagina,  while  above  the  pelvis  is  filled  with  a  cancerous 
mass  in  which  are  recognized  with  difficulty  the  fundus  of  the 
uterus  and  the  appendages.  Even  these  in  their  turn  may  be  per 
forated.  Metastatic  productions  are  sometimes  seen  in  the  distant 
viscera — the  liver,  the  lungs,  the  stomach,  and  the  kidneys.  The 
iliac  ganglia,  prevertebral  and  ingumal,  are  often  invaded.  Troisier 
has  recently  caUed  attention  to  the  left  supra-clavicular  adenopathy 
sometimes  produced  independently  of  invasion  of  the  lungs,  or 
prevertebral  ganglia  in  abdominal  cancer  in  general,  and  in  par 
ticular  in  uterine  cancer.  This  is  probably  due  to  direct  infection 
by  contaminated  lymph  and  is  a  valuable  clinical  symptom  for 
centra-indications.  To  the  number  of  secondary  lesions  it  is  neces- 
sary to  add  fatty  degeneration  of  the  liver. 

Symptoms. — The  commencement  is  insidious  and  it  can  be  said 
that  there  exists  first  a  latent  period  during  which  the  patients 
preserve  all  the  appearances  of  health,  even  with  advanced  lesions. 
This  is  why  the  initial  alterations  are  so  seldom  observed.  The 
attention  is  frequently  attracted  for  the  first  time  by  a  loss  of  blood, 
often  trifling,  outside  the  menstrual  period,  after  fatigue,  often 
after  coitus  or  straining  at  stool.  But  this  accident,  occurring 
often  with  women  who  approach  the  menopause,  is  taken  for  an 
unimportant  irregularity  and  passed  unnoticed,  it  only  disturbs 
finally  by  its  repetition.  Even  htemorrhages  appearing  regularly 
every  month  are  sometimes  taken  for  a  return  of  menstruation 
and  are  rather  welcomed  with  satisfaction  by  some  women  who  see 
in  it  a  sort  of  return  of  youth.  These  first  hnemorrhages  are  not 
furnished  by  an  ulcerated  surface  ;  they  are  due  to  the  concomitant 
metritis,  or  simply  to  a  flexion  provoked  by  the  presence  of  the 
neoplasm  acting  as  an  irritant ;  this  process  may  be  compared  to 
•that  of  haemoptysis  in  the  first  stage  of  pulmonary  tuberculosis. 

Leucorrhcea  also  commences  at  this  time,  but  without  special 
character.  At  last,  pains,  reflex  phenomena  on  the  side  of  the 
digestive  tract,  of  the  circulation  and  of  the  nervous  system,  repro- 
duce the  pathological  cycle  that  I  have  mentioned  in  the  chapter 
on  metritis  under  the  name  of  uterine  syndrome. 

A  diagnosis,  however,  cannot  be  made  without  the  aid  of  local 
examination.     Touch  makes  known  the  induration,  the  papillary 


218  Cancer  of  the  Cerviv  Uteri. 

or  ulcerated  state  of  the  cervix ;  examination  A\-ith  the  speculum 
shows  the  livicl  aspect  of  tumefaction,  or  yellow  ulcerated  sm-face, 
and  the  cauhflower  vegetation  or  fungus.  I  have  described  apropos 
of  pathological  anatomy  the  different  forms  that  may  be  observed 
at  the  beginning. 

Soon  after  comes  a  second  period,  which  might  be  called  the 
acme  of  the  disease.  All  the  phenomena  are  marked.  Hemor- 
rhage becomes  more  frequent,  the  discharge  being  red  or  reddish, 
like  that  from  an  abrasion.  It  has  an  insipid  sickening  odor,  or 
fetid  and  repulsive ;  its  abundance  and  irritating  effect  produce  an 
erythema  of  the  tlughs  and  a  most  painful  pruritis  of  the  vulva.  At 
the  same  time  the  pains,  especially  lumbar,  become  stronger  and 
diverse  neuralgic  irradiations  are  added.  At  this  time,  by  touch, 
the  vaginal  culs-de-sac  may  stiU  be  found  fi-ee,  but  often  they  are 
already  invaded.  The  uterus  may  still  remain  movable,  or  be 
rendered  more  or  less  immovable  by  propagation  to  the  pelvic 
cellular  tissue.  I  insist  especially  on  the  superiority  of  the  infor- 
mation gamed  by  touch  and  bimanual  palpation  over  that  furnished 
by  the  speculum.  One  is  surprised,  if  the  natural  order  of  these 
explorations  is  reversed,  to  find  with  the  finger  very  much  more 
extensive  alterations  than  have  l)een  perceived  by  sight.  Sometimes 
the  cemx,  which  appears  barely  tumefied  and  slightly  ulcerated  by 
the  speculum,  is  perceived  by  the  touch  as  a  large  tumor,  deeply 
fixed  by  advanced  growth.  Digestive  troubles,  anorexia,  const! 
pation,  tj^npanites,  are  very  important  at  tliis  period  and  com 
promise  the  general  nutrition. 

Soon  the  third  phase  arrives,  or  cancerous  cachexia ;  the  skin 
takes  a  pale  yeUow  tint,  which  Barnes  has  long  attributed  to  ab- 
sorption of  part  of  the  decomposed  fecal  matter,  retained  in 
obstinate  constipation  (coprfemia).  It  also  shows  a  particular 
dryness  and  roughness.  It  is  in  tliis  peiiod  that  the  painful  phe- 
nomena of  cystitis,  intolerable  neuralgia,  produced  by  pressure  or 
invasion  of  the  nerves,  phlegmasia  alba  dolens  and  fistulae  are 
observed.  Local  examination  reveals  the  extension  of  the  new 
gi-owth  to  neighboring  parts.  Uraemia  is  uow  present ;  aualj'sis  of 
the  urine  shows  scanty  secretion.  This  is  due,  not  only  to  general 
debility,  but  also  to  insufficiency  of  renal  filtration.  The  exacer- 
bation of  the  gastric  sjinptoms,  vomiting,  etc.,  are  without  doubt 
induced  by  successive  slight  attacks  of  subacute  lu'semia.  But,  little 
by  little,  the  ur<iemia  becomes  chronic,  and  then  it  becomes  a  real 
benetit  to  the  patient,  whose  intelligence  and  sensibihty  it  blunts. 
They  still  hve  some  days  in  a  semicomato.se  state,  hardly  answering 
questions,  incapable  of  motion  and  indifferent  to  their  surroundings. 
Then  they  pass  a^\•ay  quietly ;  this  is  the  way  in  which  most  patients 
die.  It  is  very  rare  to  observe  convulsions  in  the  form  of  eclampsia. 
I  have  seen  an  example  of  the  dyspnoeic  form  of  uraemia.     Peri- 


Cancer  of  the  Cevvix  Uteri.  219 

touitis  by  propagation  or  by  perforation,  emboHsm,  may  eairse  a 
more  sudden  death.  It  is  evident  that  septictemia,  due  to  absorption 
of  putrid  material,  is  an  important  factor  in  the  final  result,  es- 
pecially if  suitable  treatment  is  not  instituted.  It  may  then,  alone, 
cause  death. 

Cmnplication  from  pregnancy . — Conception  may  take  place  when  a 
cancer  of  the  cervix  exists  ;  exact  observations  prove  it,  although  it 
is  evidently  a  very  unfavorable  condition  to  fecundation.  In  many 
cases  women  have  returned  to  the  physician,  again  pregnant, 
althoi;gh  in  the  preceding  delivery  a  cancer  had  been  found.  Cancer 
predisposes  to  abortion.  If  the  sixth  month  is  passed  there  is  a  good 
chance  of  going  nearly  or  quite  to  term.  Prognosis  for  a  cancerous 
woman  is  made  still  more  grave  by  pregnancy.  First,  because 
abortion  may  cause  a  fatal  haemorrhage  or  septicemia ;  and  second, 
because  deUvery  at  term  is  very  dangerous. 

Diagnosis. — I  have  already  spoken  of  the  differential  diagnosis 
between  cancer,  at  its  beginning,  before  ulceration,  and  chronic 
metritis,  and  between  cancer,  after  ulceration,  and  catarrhal  me- 
tritis of  the  cervix.  The  vegetations  formed  bj^  a  benigii  papilloma 
that  are  observed  in  vaginitis  and  on  the  edge  of  mucous  patches, 
should  not  be  confounded  with  the  fungosities  of  cancer.  Their 
multiplicity,  their  dissemination  and  the  characteristic  appearance 
are  sufficient  to  avoid  error.  Finally,  the  reddish  and  fetid  discharge, 
so  different  fi-om  the  purulent  flow  of  vaginitis,  scarcely  ever  exists 
except  in  epithelioma.  A  circumscribed  nodule  of  the  cervix  can 
only  be  distinguished  with  difficulty  from  a  small  myoma.  However, 
the  latter  is  more  clearly  limited  and  there  is  no  sign  of  infiltration 
or  inflammation  around  it.  The  mucosa  is  not  adherent  to  the 
fibroid  as  in  cancer.  Some  cylindrical  epitheliomata  of  the  cervix 
present  a  polypoid  appearance,  which  may  be  confounded  with 
mucous  polypi  of  benign  nature.  This  may  be  true  of  cancerous 
granulations  of  the  mucosa  of  the  cervix  that  project  externally. 
Dilatation,  uterine  touch,  and  an  exploratory  curetting  make  the 
differential  diagnosis. 

All  these  considerations  relate  to  cancer  in  its  first  stage.  Later, 
the  invasion  of  contiguous  parts,  the  progress  of  the  ulceration,  the 
frequence  of  the  haemorrhages,  and  the  abundance  of  the  fetid 
secretion  make  diagnosis  easy.  There  is,  however,  one  affection 
with  which  it  may  be  confounded  at  this  period,  that  is  a  fibroid  of 
the  cervix  or  a  polypus  of  the  body,  arrested  by  strangulation,  or 
by  adhesions  at  the  external  os,  when  the  tumor  has  been  altered  by 
a  spontaneous  decomposition  or  by  untimely  application  of  caustics. 
Haemorrhages,  fetid  discharge,  the  fungous  and  sloughing  aspect  of 
the  neoplasm  add  then  to  the  confusion.  The  patient,  debilitated  by 
a  profound  anaemia,  may  even  appear  attacked  by  cancerous 
cachexia.     There  is  only  one  symptom  which  corrects  the  error,  but 


220 


Cancer  of  the  Cervix  Uteri. 


it  is  pathognomonic.  The  external  orifice  of  the  cervix  should 
always  be  sought.  In  the  case  of  a  fibroid,  it  is  felt  hke  a  collar, 
thin,  but  continuous,  around  the  tumor,  and  the  finger  can  be  intro- 
duced between  this  ring  and  the  tumor.  The  growth,  also,  in  its 
marginal  portion,  is  smooth,  firm  and  free  from  ulceration. 

Apropos  of  diagnosis,  there  are  some  exceptional  forms  of  ma- 
lignant tumors  of  the  cervix.  Hegar  found  a  very  rare  case  in  an 
old  woman.  The  cer\ix  was  hyper trophied  and  projected  thi-ough 
the  vulva  without  presenting  the  least  ulceration.  Eckhardt  has 
oijserved  in  a  girl  of  nineteen  a  considerable  hypertrophy  of  the 
carvix,  which  had  apparently  been  immediately  preceded  by  a  carci- 
nomatous degeneration.  Schroeder  found  in  an  autopsy  an  intra- 
cervical  cancer  of  the  upper  part  of  the  ceiwix  that  was  not  apparent 
on  the  exterior. 


Fig.    105. — Myxosarcoma  of  the  cervix  (Pernice).     Z,  line  of  excision;    a  a  6, 
grains  of  the  tumor ;  c,  remains  of  a  thin  enveloping  membrane. 

Sarcoma  of  the  cervix  has  been  observed  so  rarely  that  it  caimot 
be  considered  as  constituting  a  characteristic  cUnical  entity.  Spie- 
gelberg  has  described  a  curious  case  that  he  calls  sarcoma  colli  hydro- 
picum  iMpillce,  in  a  young  girl  of  seventeen.  It  was  a  papillary 
tumor  of  the  anterior  lip  of  the  cervix,  which  returned  ten  months 
after  ablation  and  fiUed  the  whole  vagina  with  a  mass  similar  to  a 
hydatiform  mole  of  the  chorion.  Microscopically  there  was  the 
structure  of  sarcoma  with  an  cedematous  infiltration.  Ludwig 
Pernice  has  given  a  description  of  a  myo-sarcoma  in  grapeform 
(Fig.  105)  observed  in  a  nuUiparous  woman.     The  tumor  sprang 


Cancer  of  the  Cei'vix  Uteri.  221 

from  the  mucosa  of  the  cervix,  was  about  the  size  of  the  fist  and 
resembled  a  bunch  of  raisin  grapes,  having  violet-colored  grains 
containing  a  gelatinous  fluid.  Munde  has  observed  an  evidently 
malignant  tumor  that  he  calls  a  myo-adenoma,  transformed  into  a 
myo-sarcoma.  It  appeared  to  be  an  example  of  mahgnant  degener- 
ation of  a  polypus,  at  first  benign. 

Thiede  has  described  under  the  ieivn,  fibroma  papillare  cartilagi- 
nescens,  a  recurring,  lobulated,  spongy  tumor.  On  microscopic 
section,  a  fibrous  stroma  containing  cartilage  cells  was  found,  but 
none  of  the  characteristics  of- sarcoma.  By  the  side  of  this  may 
be  placed  a  curious  case  of  Kein,  described  as  myxoma  enchondro- 
matodes  arborescens  colli  uteri.  This  was  a  soft,  lobulated,  recurrent 
tumor.  On  section  the  soft  tissue  was  seen  to  be  subdivided  by 
fibrous  fasciculi  into  alveoli  containing  gelatinous  substance  and 
some  nodules  of  hyaline  cartilage.  Finally,  Winckel  has  described 
an  adeno-myx.oma  cerincis.  Microscopical  examination  demonstrated 
the  existence  of  a  mixed  tumor,  which  had  probably  been  an  ade- 
noma in  the  beginning  and  was  then  transformed  into  sarcoma  with 
final  myxomatous  degeneration.  The  rare  facts  that  I  have  cited 
are  worthy  of  mention  from  a  nosological  point  of  view,  but  in  the 
eye  of  the  clinician  they  are  equally  cancers. 

An  important  part  of  diagnosis  is  the  determination  of  the  extent 
of  the  cancerous  invasion.  Bimanual  exploration  will  give  precise 
information  on  this  point.  If  necessary,  anaesthesia  may  be 
employed,  as  tMs  exploration  is  very  important  from  an  operative 
point  of  view. 

Prognosis. — Cancer  in  aU  its  forms  pursues  a  fatal  course.  But 
some  forms  are  of  slow  evolution,  for  example,  the  scirrhus  variety 
of  the  cervical  cavity.  The  average  duration  of  the  disease  is  from 
sixteen  to  seventeen  months,  according  to  Courty ;  twelve  months, 
according  to  Gusserow.  Simpson  gives  two  years  to  two  and  one- 
half.  Exceptional  cases  of  long  duration  have  been  cited.  The  age 
of  the  patient  is  of  importance.  Generally  cancer  in  women  of 
twenty  to  tliirty  years  is  of  much  more  rapid  evolution  than 
in  those  toward  the  menopause.  In  cancers  of  galloping  progress 
rapid  return  is  observed  even  after  hysterectomy  made  under  the 
most  favorable  conditions ;  these  cases  generally  occur  in  very  young 
subjects.  The  variety  of  cancer  is  of  equal  importance.  There  are 
some  that  bleed  but  little  and  are  not  vegetating,  that  may  take 
years  for  their  evolution,  especially  if  the  patient  is  at  a  certain  age. 

JEtiology. — Women  are  more  subject  to  cancer  than  men,  and  the 
uterus  is  the  organ  most  frequently  attacked.  It  is  during  the  period 
we  may  caU  the  uterine  life  of  women,  from  puberty  to  the  meno- 
pause (when  it  attains  its  maximum),  that  this  frequent  appearance 
of  cancer  is  manifest.  After  the  uterus  the  breast  is  most  fre- 
quently attacked. 


222  Treatment  of  Cancer  of  the  Cervix. 

There  are  some  predisposing  causes  that  have  an  intlueuce  that 
cannot  be  denied.  The  intluence  of  race  is  marked  in  America. 
According  to  Chisholm's  statistics,  one  out  of  everj'  one  hundred 
whites,  men  and  women,  die  of  cancer,  and  only  one  out  of  thi-ee 
hundred  negroes  of  both  sexes  succumb.  Heredity  has  been  denied. 
Schroeder  found  that  out  of  nine  hundred  and  forty-eight  cases, 
hereditary  influences  were  found  in  seventy-eight.  1  have  seen 
several  undeniable  examples.  The  most  favorable  age  is  from  forty 
to  fifty  years.  The  most  valuable  statistics  are  those  collected  by 
Gusserow,  3,385  cases ;  the  greater  proportion  (1,169)  occurred 
between  the  ages  of  forty  to  fifty.  Privation  certainly  favors  cancer 
as  it  is  especially  observed  among  the  lower  classes  of  people.  This 
is  contrary  to  what  has  been  observed  with  regard  to  the  myomata. 

The  local  predisposing  causes  that  have  been  invoked  especially 
are  laceration  of  the  cervix,  and  the  cervical  metritis  that  this  causes 
(Emmet,  Breisky).  Eepeated  parturition  has  also  been  assigned  as 
a  cause  (Gusserow),  but  it  is  possible  that  they  only  act  tlu-ough  the 
lacerations  and  the  inflammations  of  the  cervix,  that  follow  as  a 
consequence. 


CHAPTER  XV. 


TREATMENT  OF  CANCER  OF  THE  CERVIX. 

The  therapeutics  of  cancer  of  the  uterus  may  be  considered  under 
two  heads :  first,  therapeutic  cases  in  which  a  radical  cure  may  be 
attempted;  second,  the  treatment  of  cases  amenable  to  palliative 
measures.  Kadical  cure  maj'  be  hoped  for  only  in  cases  of  cancer 
limited  to  the  organ,  mthout  invasion  of  the  contiguous  tissues. 
PaUiative  treatment  is  addressed  to  cancer  extending  beyond  the 
uterine  hmits,  in  which  total  ablation  will  be  either  impossible,  too 
dangerous,  or  useless.  For  greater  clearness,  I  will  follow  this 
general  di^^sion  in  passing  in  review  the  various  degrees  of  the 
disease  and  different  opinions  on  their  treatment. 

I.  Cancer  limited  to  the  cervir,  not  extending  to  the  vaginal  cids-de- 
sac. — Until  late  years  radical  cure  of  cancer  of  the  uterus  was  only 
attempted  in  cases  where  it  was  clearly  hmited  below  the  vaginal 
insertion,  and  infravaginal  amputation  was  performed.  This 
operation  gave  good  results  to  Verneuil,  who  advised  the  ecraseur, 
and  to  Braun,  who  employed  the  galvano-cauterj'  loop.  Schroeder 
advises  the  knife.     I  believe  that  the  use  of  the  knife  is  both  more 


Treatment  of  Cancer  of  the  Cervix.  223 

expeditious  and  more  certain  than  the  ecraseur  and  the  galvano- 
cautery,  as  these  methods  are  hable  to  be  followed  by  stenosis  of  the 
cervix.  Schroeder  employs  either  conoidal  excision,  or  better,  the 
excision  of  the  disease  in  a  wedge-shaped  piece,  from  each  lip  sepa- 
rately, after  having  deeply  incised  the  cervix.  I  consider  the  use  of 
the  knife  as  superior  to  all  other  methods.  It  obviates  the  danger 
of  an  accidental  opening  of  the  peritonaeum.  It  permits  all  the 
manoeuvres  to  be  made  intelligently,  and  not  wholly  mechanically, 
and  allows  ablation  to  be  pushed  to  the  requisite  extent.  I  use,  then, 
amputation  with  the  knife,  if  I  believe  it  indicated,  and  according 
to  the  teclmique  given  in  treating  of  the  metrites.  But  I  wish 
further  to  say,  that  if  the  lesion  is  cancerous,  however  limited  its 
extent  may  be,  I  practice  total  hysterectomy.  My  only  reason  for 
including  here  the  technique  of  the  ecraseur  is  the  high  authority  of 
ProfesscQ'  Verneuil. 

First  stage. — Subvaginal  amputation  of  the  cervix.  —  Verneuil' s 
method. — Perforation  of  the  cervix. — The  patient  being  placed  in  the 
lithotomy  position,  the  assistant  depresses  the  perinseum  with  a 
Sims'  speculum.  The  cervix  is  drawn  down  with  a  volseUa  and  trans- 
fixed with  two  strands  of  stout  silk  ligatures  passed  at  right  angles  to 
the  axis  of  the  cervix  above  the  growth.  One  loop  is  used  to  draw 
the  chain  of  the  ecraseur  into  place ;  the  other  serves  to  draw  the 
cervix  gently  downward. 

Second  STAGE. — lutrocluction  of  the  chains. — This  stage  presents 
no  difficulty.  Naturally  care  is  taken  to  turn  the  concave  side  of  the 
chain  toward  the  cervix.  To  do  this  the  chain  should  be  placed  as 
nearly  as  possible  at  right  angles  to  the  cervix ;  the  tliread  remaining 
in  place  is  used  to  draw  the  uterus  downward  and  to  the  side  oppo- 
site to  the  chain.  Then  the  handle  of  the  ecraseur  is  carried  up  and 
the  constricting  ring  held  with  the  nail  of  the  left  index  finger,  until 
it  has  traced  a  groove  in  the  tissues  of  the  cervix.  If  the  operator 
possesses  two  curved  ecraseurs  the  second  chain  may  be  placed 
immediately  after  the  first  by  following  the  same  method.  The  two 
instruments  are  used  at  once,  thus  cutting  the  operation  much 
shorter.  If  only  one  ecraseur  is  at  disposal,  the  remaming  loop  is 
tightly  tied  around  its  half  of  the  cervix,  as  if  on  a  pedicle.  When 
the  first  section  is  finished  the  uterus  is  drawn  down  and  the  chain 
placed  in  the  groove  produced  by  this  ligature. 

Third  stage. — Section  of  the  cervix. — This  should  be  made  with 
great  slowness,  if  a  really  bloodless  operation  is  desired.  As  soon 
as  the  chain  has  been  tightened  sufiiciently  to  feel  the  resistance  of 
the  tissues  the  movement  is  made  slower,  advancing  a  notch  every 
thirty  seconds.  When  a  peculiar  sound  announces  that  the  tissues 
tear  under  the  pressure  the  intervals  are  decreased  to  ten  seconds. 
It  is  important  to  make  the  section  slowly  if  bleeding  is  to  be  pre- 
vented. 


224  Treatment  of  Cancer  of  tlie  Cervix. 

Dressings ,-  After-treatment. — After  completing  the  amputation  the 
portion  removed  is  examined  with  care  to  see  if  the  section  has 
included  all  the  diseased  tissues,  and  if  the  peritoneal  cul-de-sac  has 
been  involved.  If  the  peritonaeum  has  not  been  invaded,  a  carboUzed 
injection,  2-100,  is  gently  thrown  into  the  vagina  until  the  liquid 
returns  colorless  or  only  slightly  tinted.  If  the  peritonaeum  has 
been  wounded,  it  will  be  pnident  to  place  some  sutures,  although  in 
some  cases  occlusion  will  be  spontaneous.  If  the  examination  of  the 
section  shows  some  diseased  portions  stUl  persisting  in  the  uterine 
stump  and  if  complete  extirpation  cannot  be  hoped  for.  the  speculum 
is  introduced  and  effort  is  made  to  destroy  the  last  vestiges  of  the 
disease  -with  the  curette  or  with  the  thermo-cautery.  The  dressings 
are  very  simple.  VemeuU  places  on  the  vulva  a  compress  of  anti- 
septic gauze,  carboUc  or  iodoform. 


Fig.  io6. — Supravaginal  amputation  of  the  cervix, 

n.  Cancer  oftJie  whole  of  the  cervix  extending  to  the  level  of  vaginal 
culs-de-sac  {exclusively). — If  only  a  partial  amputation  is  intended 
the  infravaginal  operation  is  not  sufficient.  It  is  necessary  to  tmn 
to  a  supravaginal  excision.  Several  surgeons  have  introduced 
modifications  of  the  method  of  eonoidal  section,  but  Schroeder  has 
given  it  the  gi'eatest  extension  and  described  its  technique  under  the 
term  supravaginal  amputation  of  the  cervix.  He  describes  the 
operation  as  follows  :  The  diseased  cervix  is  di-awn  down  viith.  the 
volsella  to  the  entrance  of  the  vagina,  and  a  strong  thi'ead  is  passed 
through  and  above  each  lateral  eul-de-sae  (Fig.  lOG).  These  loops 
serve  to  draw  the  parts  downward  and  they  can  be  used  to  control 
the  uterine  artery  and  its  branches.  On  completing  the  excision 
they  constitute  the  sutures  at  the  fundus  of  the  culs-de-sac.  An 
incision  as  far  as  the  connective  tissue  is  then  made  at  the  edge  of 
the  anterior  Hp  to  at  least  one  centimetre  from  the  diseased  tissues. 


Treatmient  of  Cancer  of  the  Cervix. 


225 


The  bladder  can  be  easily  separated  from  the  anterior  wall  of  the 
cervix,  to  a  sufficient  extent,  by  tearing  the  loose  connective  tissue 
interposed.  The  volsella  is  then  drawn  forward  so  as  to  expose  the 
posterior  cul-de-sac,  and  the  posterior  wall  of  the  vagina  is  incised. 
Greater  difficulties  are  found  in  separating  the  peritonaeum  from 
the  posterior  wall  of  the  vagina.  If,  on  account  of  the  extension  of 
the  neoplasm,  it  becomes  necessary  to  make  a  very  high  incision  in 
the  posterior  cul-de-sac,  there  is  danger  of  opening  the  peritonaea! 
cavity,  and  even  if  this  can  be  avoided,  there  is  still  the  danger  of 
erosions  of  the  dehcate  serous  membrane.  The  peritonaeum  can  be 
easily  recognized ;  even  before  it  has  been  encroached  on,  it  j)resents 
the  aspect  of  a  bluish,  transparent  bladder.  If  the  serosa  has 
been  opened,  it  is  closed  on  completing  the  operation  by  several 
sutures  of  very  fine  thread.     The  vagina  being  thus  di^dded  in  front 


Fig.  107. — Amputation  of  the  cervix      A.  Infravaginal.     B.  Supravaginal. 

and  behind,  the  incisions  are  prolonged  to  the  sides  until  they  meet. 
The  cervix,  thus  disengaged,  is  then  detached  from  the  connective 
tissue  by  tearing  its  attachments  with  the  finger.  At?  the  sides  it  is 
more  difficult  to  detach  the  cervix,  as  at  this  point  the  cellular  tissue 
is  firmer  and  large  arteries  penetrate  the  uterus.  The  vessels  are 
cut  after  having  hgated  them.  As  soon  as  the  cervix  is  suf- 
ficiently disengaged,  the  anterior  wall  is  incised,  sinking  the  knife 
to  the  cervical  canal.  Then  sutures  are  passed  through-the  anterior 
cul-de-sac  and  along  the  posterior  wall  of  the  bladder,  traversing 
the  anterior  uterine  waU  and  emerging  finaUy  in  the  cervical  canal 
(Fig.  107).  These  are  tied,  and  the  surface  of  the  section  of  the 
anterior  vaginal  wall  applies  itself  to  the  surface  of  the  section  of 
the  cervical  tissues.  Tliis  suture,  by  embracing  all  the  parts,  closes 
thus  the  wound  in  the  connective  tissue.  If  the  posterior  wall  of 
the  uterus  has  already  been  divided  these  sutures  prevent  the  stump 


226  Treatment  of  Cancer  of  the  Cervix. 

from  ascending.  Similar  sutures  are  used  to  embrace  the  deep 
parts  and  unite  the  posterior  vaginal  wall  and  the  posterior  lip  of 
the  uterus.  The  union  is  consolidated  by  placing  new  lateral  sutures 
and  the  operation  is  terminated  by  closing  with  ligatm-es,  placed  as 
deeply  as  possible,  ah  the  raw  surface.  This  operation  permits 
removal,  in  great  part,  of  the  vaginal  culs-de-sac,  the  cervix,  and 
even  a  small  portion  of  the  body  of  the  uterus. 


Fig.  ioS. — Relations  of  the  ureters  and  the   uterine  arteries  with  the  cervix.     U, 
uterus ;  Ur,  ureter ;  AU,  uterine  arteiy  ;  C,  cervix  ;  V,  bladder ;  Va,  vagina. 

In  spite  of  much  discussion,  surgeons  are  far  from  being  in  accord 
as  to  a  choice  between  partial  amputation  and  total  extuijation.  It 
is  probable  thait  the  opinion  of  the  majority  of  the  adversaries  of  the 
latter  will  be  considerably  modified  when  it  is  demonstrated  that 
total  hysterectomy  is  not  sensibly  more  formidable  than  partial 
hysterectomy,  when  it  applies  to  the  same  cases.  Now  this  demon- 
stration is  close  at  hand  in  statistics.  I  believe  also  that  hsmo- 
stasis  and  antisepsis  are  more  easily  attained  in  total  hysterectomy 
than  in  supravaginal  amputation.  The  great  argument  of  the 
opponents  of  early  hysterectomy  appears  then  to  be  almost  destroyed, 
and  the  importance  of  the  considerations  in  favor  of  radical  inter- 
ference is,  in  consequence,  considerably  enhanced.  The  princiijal 
of  these  reasons  is  the  impossibility  of  affirming  that  the  disease  is 
limited  to  the  cervix  and  that  it  has  not  pushed  a  prolongation  along 
the  mucosa  toward  the  body.     Examination  by  touch  and  by  the 


Treatment  of  Cancer  of  the  Cervix. 


227- 


speculum  for  determining  this  point  is  unreliable.  A  second  mode, 
more  rare,  of  the  hidden  extension  of  cancer,  that  camiot  be  diag- 
nosticated on  the  living,  is  the  formation  of  metastatic  nuclei  in  the 
body  of  the  uterus  with  an  isolated  cancer  of  the  cervix.  And  ev^en 
when  the  accompanying  lesions  of  the  mucosa  of  the  body  do  not 
take  on  the  sarcomatous  character  mdicated  by  Abel  and  Landau, 
it  is  not  the  less  certain  that  they  constitute  a  locus  minorls  resistentice 
which  favors  recurrence. 


Fig.  109. — Vessels  of  the  uterus.     Uterine  and  utero-ovarian  arteries. 


III. — Cancer  of  the  cervix  tvith  invasion  of  the  body,  'without  propa- 
gation to  the  contiguous  tissues. — On  these  cases  there  is  scarcely  any 
discussion  to-day  and  the  majority  of  gynaecologists  are  m  accord 
in  practicing  total  extirpation  or  hysterectomy  by  the  vagina.  This 
operation,  which  has  been  termed  in  a  single  word  colpohysterectomy, 
is  of  relatively  ancient  date  and  has  enjoyed  an  ephemeral  popu- 
larity for  half  a  century.  But  it  has  only  recently  been  revived 
by  Czerny, 

Colpohysterectomy  or  vaginal  hysterectomy. — Before  operating  one 
should  be  assured  by  careful  examination  of  the  diseased  i^art  that 
the  uterus  is  mobile  and  that  the  broad  ligaments  are  fi'ee.  For 
this,  bimanual  palpation,  rectal  touch  and  depression  of  the  uterus 
with  the  fixation  forceps  are  indispensable.  Sometimes,  in  doubtful 
cases,  examination  under  anaesthesia  wiU  be  necessary.  Another 
preUmiuary  precaution  consists  in  as  complete  disinfection  of  the 
vagina  as  possible  some  days  before  the  operation.     If  the  cervix  is 


2-28 


Treatmevt  of  Cancer  of  the  Cervix. 


covered  by  friable  vegetatioub,  giving  rise  to  a  fetid  disintegration, 
it  is  necessary  to  make,  a  week  before  the  operation,  a  superficial 
curetting  to  clean  the  operative  field  and  prevent  its  infection.  It 
is  not  necessary  to  anaesthetize  the  patient,  for  tliis  is  not  painful. 
Profuse  irrigations  of  sublimate,  1-5000,  twice  a  day  before  the 
operation,  with  the  api^lication  in  the  interval  of  iodoform  tampons, 
will  complete  this  preparation. 

The  patient  shoiild  be  ]purged  the  evening  before ;  three  hours 
before  the  operation  she  should  have  a  bath  and  immediately  before 
the  moment  of  operating  an  assistant  (who  should  take  no  direct 
part  in  the  operation)  ascertains  by  rectal  touch  that  the  intestine 
is  entirely  empty.  If  it  is  not,  the  assistant  will  immediately  give 
an  enema  of  hot  water  and  with  the  aid  of  the  finger,  if  necessary, 
will  thoroughly  evacuate  the  rectum.  For  this  purpose  a  rectal  irri- 
gation of  boric  acid  solution  (50  gi'ammes  per  litre)  may  be  used. 
The  bladder  should  be  emptied  at  the  moment  of  operation  by  an 
assistant. 


Fig.  ho. — Vaginal  hysterectomy.     Opening  of  the  posterior  cul-de-sac 
and  suture  of  the  vagina  (Martin). 

The  patient  is  ansesthetized  and  then  placed  in  the  dorso-sacral 
position,  and  an  assistant  on  each  side  holds  the  leg  flexed  under 
one  of  his  arms  while  the  other  remains  fi'ee  to  assist  the  operator. 
The  fourchette  is  depressed  with  a  speculum,  the  lateral  parts 
drawn  apart  with  the  retractors.  The  cer^dx  is  grasped  \vith  the 
volsella  and  continuous  ii-rigation  is  gently  commenced  upon  the 
operating  field. 


Treatment  of  Cancer  of  the  Cervix.  229 

First  stage. — Opening  of  Douglas'  cul-de-sac  and  vagino-peritoncBol 
sutv/re. — The  surgeon  carries  the  cervix  very  strongly  forward  so  as 
to  make  the  posterior  cul-de-sac  tense  and  this  he  incises  in  all  its 
extent  as  far  as  the  peritonaeum.  The  index  finger  of  the  left  hand 
is  insinuated  in  this  button-hole,  and  with  a  strongly-curved  needle 
a  series  of  sutures  is  placed  aU  along  the  vaginal  edge,  comprising 
all  the  thickness  of  the  tissues  to  the  peritonaeum,  inclusive.  By 
proceeding  thus,  there  is  obtained  a  perfect  hsemostasis  on  the  side 
of  the  vaginal  vessels,  which  often  are  the  cause  of  a  troublesome 
oozing.  Besides  this,  the  cellular  spaces  are  closed  and  the  sepa- 
ration of  the  structures  that  would  be  produced  by  the  subsequent 
manoeuvres  is  prevented  (Fig.  110).  It  may  happen  that  the 
posterior  insertion  of  the  vagina  is  at  a  very  great  height  on  the 
cervix  or  that  Douglas'  cul-de-sac  is  in  part  involved  in  adhesions. 
The  dissection,  then,  should  go  to  a  sufficient  extent  and  it  may  be 
useful  to  place  two  superposed  rows  of  sutures. 


Fig.  III. — Vaginal  hysterectomy.     Suture  of  the  vaginal  floor  (Martin). 


Second  stage. — Hemostatic  suture  of  the  pelvic  flom: — The  needles 
are  changed  for  some  that  are  longer,  stronger  and  less  curved. 
With  these  there  are  placed  on  each  side  of  the  button-hole  two 
large  stitches  including  en  masse  the  posterior  part  of  the  lateral 
culs-de-sac  of  the  vagina  and  going  deeply  down  to  grasp  at  the  base 
of  the  broad  ligaments,  the  inferior  branches  of  the  uterine  artery, 
if  not  the  trunk  of  this  vessel.  For  this  procedure  it  is  necessary 
to  place  the  finger  in  the  button-hole  and  depress  the  base  of  the 
broad  ligament  forward,  carrying  it  toward  the  suture  (Fig.  111). 


2:10  Treatment  of  Cancel'  of  the  CeiTia-. 

The  needle  enters  at  two  centimetres  from  the  angle  of  the  wound 
and  as  soon  as  the  finger  feels  the  point  it  is  grasped  with  the  forceps. 
It  is  brought  out  again  at  one  centimetre  from  its  point  of  entrj-  in 
such  a  way  as  to  enclose  almost  a  centimetre  of  the  vaginal  cul-de- 
sac.  Very  strong  sUk  should  be  used  for  this  Ugature.  Two  other 
sutui'es  are  then  passed  on  each  side  in  fi-ont  of  the  first  and  a  little 
nearer  the  cervix.  In  this  way  aU  the  vessels  are  obliterated  on  the, 
side  of  the  vagina  before  terminating  the  first  stage  of  the  oper- 
ation. Injury  to  the  ureter  is  not  to  be  feared,  as  it  is  situated  ui 
front  and  is  farther  up,  on  account  of  the  strong  traction  on  the 
cervix. 

Third  stage. — Complete  circumcision  of  the  vagina  ,-  Detachment  of 
the  bladder. — The  cervix  is  carried  backwai'd  to  make  the  anterior 
cul-de-sac  tense.  Great  care  must  be  taken  here  to  keep  as  near 
the  eeiTix  as  possible  by  gomg  clear  outside  the  diseased  tissues. 
Without  this  there  is  danger  of  womiding  the  ureter.  The  edge  of 
the  knife,  for  the  same  reason,  should  always  be  dii-ected  toward 
the  cervix.  As  soon  as  the  incision  of  the  vagina  is  finished  the 
knife  is  laid  aside  and  the  finger  is  used  to  detach  the  bladder,  only 
exceptionally  employing  the  scissors  It  should  be  remembered 
that  the  extent  and  the  fii-mness  of  these  connections  vary  accord- 
ing to  the  subject.  At  the  end  of  a  shoii  dissection  the  finger  feels 
a  want  of  resistance,  indicating  that  the  Hmit  of  the  attachments  of 
the  bladder  has  been  arrived  at.  Sometimes  the  bluish  aspect  of 
the  peritoneal  cul-de-sac  may  be  seen.  Many  surgeons  incise  it  at 
this  moment ;  I  prefer  to  leave  it  so  that  when  the  uteiiis  is  rotated 
its  ulcerated  surface  is  not  brought  against  the  peritonsum.  Before 
going  further  sutures  are  placed  in  the  section  to  arrest  the  haemor- 
rhage. 

Fourth  stage. — Rotatin;/  the  uterus ,-  Ligature  of  the  broad  liga- 
ments.—The  cervix  is  disengaged  to  its  superior  hmit.  It  is  di-av\"n 
forward,  the  posterior  part  of  the  wound  is  depressed  with  a  retractor, 
and  with  a  curved  volsella  the  posterior  part  of  the  fundus  is  seized. 
Then  the  uterus  is  made  to  s^ing  m  the  wound,  after  the  removal  of 
the  forceps,  until  it  is  inverted.  After  its  iuversion  the  broad  liga- 
ments are  ligated  in  thi-ee  divisions.  This  suture  and  the  section  are 
first  made  to  the  left.  Before  entu-ely  detaching  the  uterus,  a  stitch 
is  placed  uniting  the  last  di^"ision  of  the  ligament  to  the  commissure 
of  the  vaguial  wound.  The  same  procedure  is  followed  on  the  right 
side  and  the  operation  is  terminated  by  cutting  the  last  filaments 
that  hold  the  uterus,  ui  particular  the  anterior  peritpnneal  cul-de- 
sac,  which  is  preserved,  if  possible,  as  a  barrier  against  infection 
fi-om  the  cervix.  A  careful  cleansing  of  the  wound  is  then  made 
with  small  tampons  of  antiseptic  cotton. 

Fifth  stage. — Drainage  and  dressings.  —  One  sutiU'e  placed  at 
each  commissure  of  the  wound  narrows  it  sufficiently  without  closing 


Treatment  of  Cancer  of  the  Cervix.  231 

it.  Before  tying  the  tlii'eads  I  place,  with  the  forceps  in  Douglas* 
cul-de-sac,  in  form  of  a  drainage  tube,  a  strip  of  iodoform  gauze, 
doubled  at  its  upper  extremity  the  lower  ends  ))eing  rolled  up  in 
the  vagina  and  distinguished  by  tying  with  a  thread.  Other  strips, 
moderately  packed,  complete  the  dressing.  The  last  strips  are 
renewed  at  the  end  of  a  time  wliieh  varies  according  to  the 
abundance  of  the  sero-sanguinolent  oozing.  The  strip  placed  in  the 
cul-de-sac  is  only  removed  at  the  end  of  six  to  eight  days.  I  prefer 
this  mode  of  drainage  to  any  other.  With  regard  to  complete 
occlusion  of  the  wound,  it  has  to-day  very  few  partisans.  However, 
Hegar  and  Kaltenbach  still  adopt  this  procedure. 

Should  the  appendages  be  saved  or  removed  ?  If  the  ovaries  and 
the  tubes  are  prolapsed  into  the  wound,  they  should  be  removed. 
If  it  is  necessary  to  search  for  them,  the  choice  of  procedure  will 
differ  according  as  the  woman  is  a  menstruating  woman  or  has 
passed  the  menopause.  In  the  first  case,  they  should  be  removed. 
They  may  be  searched  for  quickly  and  generally  may  be  easily 
extirpated.  If  removal  is  very  difficult  in  consequence  of  adhesions, 
it  is  better  to  leave  them,  and  risk  some  subsequent  accidents,  than 
to  complicate  the  operation. 

The  final  treatment  is  very  simple ;  if  the  iodoform  tampons  are 
not  too  much  soiled  with  blood  they  may  be  left  in  place  four  days. 
At  the  end  of  the  first  week  both  the  tampons  and  the  drainage 
strip  are  removed.  The  peritonseal  wound  has  already  been  closed 
some  time  by  false  membranes.  It  is  not  the  less  necessary  to  be 
prudent  in  the  use  of  vaginal  injections,  beginning  them  only  at  the 
end  of  eight  days  (sublimate  1-5000),  under  low  pressure,  and  keep- 
ing the  perinseum  strongly  depressed.  At  the  end  of  three  weeks 
the  patient  is  permitted  to  be  up  and  the  silk  sutures  in  the  fundus 
of  the  vagina  are  then  sought  for.  Two  or  three  sittings,  at  some 
days'  interval,  are  generally  necessary  to  take  them  all  out.  It  is 
better  not  to  leave  them  to  come  away  of  themselves,  as  they  pro- 
duce irritation  and  leucorrhcea.  During  the  first  twenty-four  hours 
the  patient  takes  very  scanty  noimshment  and  ice  to  allay  vomiting. 
I  give  a  laxative  the  third  day.  Eecovery  may  result  without  any 
elevation  of  the  temperature. 

I  have  described  the  operative  technique  that  I  have  adopted  and 
that  I  recommend.  It  is  very  nearly  that  of  Martin's  method.  I 
will  mention,  however,  by  way  of  appendix,  the  principal  modifi- 
cations of  other  authorities.  First,  second  and  third  stage. — Fritsch 
begins  by  a  dissection  of  the  lateral  culs-de-sac  and  seeks  the 
uterine  arteries  to  ligate  them.  He  then  proceeds  to  the  dissection 
of  the  bladder  and  terminates  by  the  incision  of  Douglas'  cul-de- 
sac.  Olshausen  defers  the  opening  of  this  cul-de-sac  as  long  as 
possible  for  fear  of  infecting  1he  peritonaeum.  Schatz  reserves  the 
detachment  of  the  bladder  te  the  last. 


232 


Treatment  of  Cancer  of  the  Ccrvlr. 


Sanger  and  otberw  Lave  aihiseil  ilivisii>n  of  the  vaginal  cul-de-sac 
with  the  thermo-cautery.  To  prevent  hfeuiorrhage  from  the  ulce- 
rated sui-face  of  the  cervix  Fritsch  places  an  elastic  ligature  on  it 
after  dissection.  Mueller  compresses  the  abdominal  aorta  during  the 
operation.  In  the  ease  of  narrowness  of  the  vagina  or  of  the  \'ulva 
incision  of  the  perinfeum  and  vagina  is  necessary.  These  incisions 
will  be  closed  mth  sutures  at  the  termination  of  the  operation. 
Various  models  of  forceps  have  been  devised  to  grasp  the  cervix  but 
the  simple  volsella  is  sufficient.  Mueller,  after  the  application  of 
provisional  ligatures  on  the  broad  hgaments,  divides  the  uterus  in 
halves  for  extraction.  Others  use  segementation,  but  these  pro- 
cedures involve  septic  exposure.  Fourth  stage. — BiUi'oth  does  not 
invei-t  the  uterus.  He,  with  Leopold,  Olshausen,  etc.,  uses  strong 
traction  and  detaches  it  little  by  little.  They  fear  infection  of  the 
wound.  But  this  danger  is  averted  by  a  previous  curetting  and  by 
preserving  the  anterior  cul-de-sac  until  the  close  of  the  operation. 
Czerny,  Fritsch,  Demons,  turn  the  uterus  forward.  Martin  and 
Schroeder  turn  the  uterus  backward. 


Fig   112 — Vagiml  h>sterectoiny      Forceps  on  the  base 
of  the  broid  hgiment  (Pean). 

For  haemostasis  of  the  broad  ligaments,  Olshausen  employs  the 
elastic  ligature.  He  makes  a  button-hole  in  the  peritoneum,  between 
the  bladder  and  the  uterus,  with  a  blunt  bistoury  and  passes  the 
elastic  Ugature  with  a  Deschamp's  needle.  Hegar  and  Kaltenbach 
also  recommend  the  elastic  ligature  for  the  broad  ligament,  but  only 
as  provisionally,  Demons  uses  ligatures  of  catgut.     Ligature  of  the 


Treatment  of  Cancer  of  the  Cerrlx. 


233 


broad  ligaments  with  metallic  threads  was  proposed  by  Coiidereau. 
Schroeder  and  Olshansen  tried  them  some  time  but  soon  abandoned 
them.  Jennings  makes  a  provisional  ligature  en  masse  of  the  broad 
ligament  with  a  loop  of  earbolized  silk  fastened  with  a  perforated 
shot  that  was  crushed  on  it.  He  finally  places  either  some  ligatures 
or  leaves  forceps  on  the  ligaments.  Pean  (Figs.  112, 113)  uses  forci- 
pressure  of  the  broad  ligaments  if  the  ligatures  are  troublesome. 
Kichelot  has  generalized  the  practice  of  leaving  the  forceps  and 
applies  it  to  all  cases.  A  number  of  surgeons,  chiefly  in  France, 
have  adopted  this  procedure,  but  it  appears  to  have  several  dis- 
advantages— want  of  security  against  haemorrhage,  possible  wound 
of  the  bladder,  the  ureter  and  the  intestine,  etc.,  are  obstacles  to 
complete  asepsis. 


Fig.  113. — Vagiii  il  li 


1  rectom\ 
.  broad  i.„ 


ri  tl.f  '^uiierior  border 


Fifth  stage. — ^To  avoid  recurrence  of  the  disease  by  extensive 
removal  of  the  tissues,  it  has  been  proposed  to  terminate  the  oper- 
ation by  resection  of  the  contiguous  part  of  the  vagina  or  even  of  the 
broad  ligaments.  Eichelot  advises  the  first,  even  when  the  vaginal 
Avail  is  perfectly  healthy.  Pawlik  extirpates  the  parametrium  after 
having  previously  placed  sounds  m  the  ureters.  It  is  doubtful  if 
these  modifications  are  useful,  but  they  are  certamly  dangerous. 

The  question  of  drainage  is  not  definitely  solved.  In  France  the 
majority  of  operators  leave  the  wound  open  and  introduce  one  or 
two  rubber  tubes ;  in  England  glass  tubes  are  much  used.  Martin 
employs  the  cruciform  rubber  tube,  withdrawing  it  the  tlurd  or  fouth 
day.     But  generally,  in  Germany,  there  is  a  tendency  to  close  the 


234  Treatment  of  Cancer  of  the  Cervix. 

wound.  I  believe  it  is  more  prudent  not  to  close  it  completely ;  the 
frequent  oozing  of  bloody  serum  during  the  first  hours  shows  that 
this  is  a  useful  precaution. 

Accidents. — I  have  akeady  spoken  of  haemorrhage  and  the  means 
of  avoiding  it.  The  ureter  has  been  wounded  sometimes  by  the 
knife,  a  ligature,  or  the  jaws  of  the  forceps  ;  this  is  one  of  the  great 
dangers  of  forcipressure.  When  this  accident  is  not  fatal,  it  may 
results  in  ureteral  fistula.  To  avoid  wounding  or  tying  the  ureter,  it 
is  necessary  to  keep  very  near  the  cervix ;  the  inversion  of  the  uterus 
should  be  made  only  after  having  disengaged  the  cervix  to  its 
superior  hmit,  and  it  is  much  better  to  abstain  from  placing  forceps 
deeply  on  the  broad  Hgament.  The  bladder  has  been  opened  with 
the  knife  and  even  broken  into  with  the  fingers.  This  accident  is 
almost  inevitable  in  operations  where  there  is  propagation  of  the 
gi'owth  anteriorly  (which  should  be  a  contra-indication  to  hystei'- 
ectomy).  Catherization  of  the  patient  before  operation  should  never 
be  forgotten.  When  the  bladder  has  been  cut  or  torn  it  should  be 
immediately  sutured  and  then  has  been  seen  to  heal  without  fistula. 
If  fistula  is  produced  it  is  as  a  rule  easily  repaired  afterward.  In 
all  cases  a  soft  catheter  is  left  in  the  bladder  for  some  days.  The 
rectum  can  only  be  opened  by  a  fault  of  the  operator,  or  at  least 
from  invasion  by  the  disease,  and  then  a  radical  operation  wiU  be 
more  harmful  than  useful. 

Gravity. — The  mortality  has  been  considerably  reduced  during 
late  years  To  appreciate  the  true  mortality  of  colpohysterectomy 
for  cancer  the  older  statistics  must  be  eliminated,  as  in  late  years 
the  technique  has  been  perfected  and  operators  have  acquired  a 
greater  experience.  Neither  is  it  just  to  bring  into  this  category, 
for  an  exact  judgment,  the  numbers  of  isolated  cases  pubhshed  by 
inexperienced  and  incompetent  surgeons.  W.  A.  Duncan,  in  his 
two  hundred  and  seventy-six  collected  cases  (fi'om  the  commence- 
ment of  1885),  coming  from  seventy-one  surgeons,  has  noted  that 
thirty-five  of  these  had  done  hysterectomy  only  once.  Thus  we  get 
the  mortality  inherent  in  the  operator  and  not  in  the  operation. 
The  rule  laid  down  by  Lawson  Tait  appears  reasonable.  It  consists 
in  holding  to  the  results  of  surgeons  whose  authority  and  experience 
are  beyond  dispute. 

A.  Martin,  by  addressing  himself  to  surgeons  fulfilling  this  double 
qualification,  has  obtained  a  complete  list  of  then-  results  up  to  the 
end  ot  1886,  as  foUows : 

Fritsch,  6o  operations  with    ^  deaths  (lo.i  per  lOO). 

Leopold,  42  operations  with    4  deaths  (  6.0  per  too). 

Olshausen,  47  operations  with  12  deaths. 

Schroeder  and  Hofnieier,  74  operations  with  12  deaths. 

Stande,  22  operations  with     i  death. 

A.  Martin,  66  operations  with  11  deaths. 

311  47  being  about  15  per  100. 


Treatment  of  Cancer  of  the  Cen>ix.  235 

But,  as  I  have  said,  these  statistics,  though  apparently  recent,  are 
already  too  old,  as  they  have  been  greatly  surpassed.  The  last 
statistics  that  I  have  been  able  to  find  bring  the  actual  mortality  to 
5  per  100.  Leopold  has  eighty  operations  with  only  four  deaths, 
or  5  per  cent.  Kaltenbach  has  fifty -three  operations  for  cancer  with 
two  deaths,  or  less  than  4  per  cent.  Ott  is  still  more  fortunate  with  , 
thirty  operations  and  not  a  single  death.  Pean  is  also  fortunate  in 
twenty-five  consecutive  successes.  According  to  these  figures  it 
appears  no  longer  necessary  to  discuss  the  application  of  this  oper- 
ation in  all  cases  where  cancer  has  been  diagnosticated.  I  beheve 
that  it  is  necessary  to  operate  as  soon  as  cancer  is  certam.  "  The 
more  the  disease  is  limited  the  more  the  operation  should  be 
extended."  By  removing  the  whole  of  the  uterus  from  the  beginning 
we  can  be  sure  of  leaving  nothing  of  the  disease,  and  of  avoiding 
ganglionic  engorgement  and  invasion  of  the  contiguous  structures. 

Causes  of  death  after  vaginal  hysterectomy. — They  may  be  ranged 
under  three  principal  heads :  Haemorrhage,  shock  and  septicaemia. 
Haemorrhage  may  occur  during  or  after  the  operation.  Primary 
hsemon-hage  is  always  the  result  of  a  fault  in  the  operation ;  it  may 
be  surely  avoided  by  Hgating  the  tissues,  step  by  step,  in  small 
portions,  before  di-viding  them.  Care  must  be  taken  never  to  pull 
upon  a  ligature  after  it  is  tied  and  on  that  account  the  threads 
should  be  cut  at  once  instead  of  leaving  this  step  till  the  end  of  the 
operation.  Progressive  ligature  exposes  less  to  hemorrhage  than 
the  forceps ;  if  a  ligature  gives  way  only  one  or  two  vessels  bleed, 
but  if  the  tissues  become  disengaged  from  a  large  forceps,  it  is  the 
major  part,  if  not  the  whole  of  the  broad  ligament,  which  bleeds  and 
retracts  to  a  great  depth.  We  know  of  many  cases  of  death  from 
this  cause  under  the  systematic  use  of  forceps.  Continued  or 
secondary  haemorrhage  has  been  observed  after  the  ablation  of 
cancer  of  the  uterus  which  had  invaded  the  contiguous  structures 
and  where  aU  could  not  be  removed.  In  the  case  of  secondary 
hemorrhage,  a  rare  occurence,  an  antiseptic  tamponnement  of  the 
vagina  may  be  done  with  iodoform  gauze,  if  the  loss  of  blood  is  not 
very  profuse.  In  case  of  serious  hemorrhage,  search  must  be  made 
for  the  bleeding  vessel  and  a  ligature  or  forceps  placed  on  it. 

Shock. — Under  this  vague,  yet  comprehensive,  name  very  diverse 
factors  are  grouped.  In  the  first  place  there  is  exhaustion  from 
hemorrhage,  the  importance  of  which  has  not  been  fully  recognized 
by  the  operator,  if  it  has  not  taken  the  form  of  an  accident,  for,  if 
care  is  not  taken  to  make  hemostasis  step  by  step,  some  vessels 
bleed  during  almost  the  whole  time  of  the  operation — a  very  grave 
occurrence  when  the  operation  is  prolonged  and  the  patient  is  aheady 
debilitated.  Another  cause  of  supposed  shock  is  acute  uremia,  due 
to  structural  changes  in  the  kidneys.  We  know  how  frequently 
their  lesions  follow  pressure  upon  the  ureters.     Many  affected  by 


236  Treatment  of  Cancer  of  tin  Cervix. 

cancer  live,  one  might  say,  with  a  minimum  of  uropoetic  organs,  in' 
a  kind  of  unstable  equilibrium.  If  this  precarious  state  is  broken 
in  upon  by  a  ^iolent  perturbation,  the  ursemia  winch  was  approach- 
ing or  imminent  is  quickly  precipitated.  The  operation  may  then 
act  simply  by  the  absoiption  of  chloroform,  since  its  ehmination  by 
the  kidneys  causes  a  fatal  renal  congestion,  hence  the  gra%-ity  of 
prolonged  anaesthesia.  It  also  acts  by  the  absorption  of  the  products 
of  the  wound,  the  elimination  from  which  chokes  the  renal  filter  and 
may  monopolize  the  smsill  portion  of  healthy  tissue  which  was 
hardly  sufficient  for  the  normal  depuration  of  the  economy.  The 
very  numerous  observations  on  patients  dying  from  so-called  shock 
present  clinical  and  pathological  findings  that  point  to  uriemia, 
generally  of  the  comatose  form.  Possibly,  too,  it  is  caused  more 
frequently  than  is  supposed,  and  without  being  recognized,  by  lig- 
ature of  the  ureters.  In  order  to  protect  ourselves  from  accidents, 
we  should  never  make  a  hysterectomy  on  patients  having  albumin- 
uria, or  even  a  marked  deficiency  of  sohds  in  the  urine.  If  we  go 
on  in  spite  of  these  unfavorable  conditions,  we  should  recognize  the 
gravity  of  the  prognosis,  endeavor  to  operate  rapidly  and  keep  up 
the  auiesthesia  as  short  a  time  as  possible.  I  habitually  put  my 
patients  on  a  milk  diet  for  some  daj's  following  the  operation  as 
much  to  promote  diuresis  as  for  alimentation. 

Scptkcemia. — One  of  the  pruicipal  causes  of  tliis  accident  is  the 
contamination  of  the  operative  field  by  the  debris  and  cancerous 
discharge.  To  guard  as  much  as  possible  against  tliis  danger  the 
rules  that  I  have  indicated  must  be  observed :  preliminary  or 
extemporaneous  curetting  of  the  fnngous  parts ;  continued  irrigation 
during  the  operation ;  keeping  a  protecting  baiTier  between  the  eemx 
and  peritonaeum ;  avoidance  of  segmentation ;  guarding  against 
crushing  the  tissues  with  forceps ;  rigorous  antisepsis. 

Survival  after  hysterectomy. — Though  the  operation  is  still  of  recent 
date,  a  copious  literature  on  this  subject  has  ah-eady  accumulated. 
The  most  extensive  data  that  we  possess  is  fmniished  by  Hache. 
The  following  table  affords  a  resume  which  I  submit,  with  the 
remark  that  it  relates,  unfortunately,  to  a  relatively  old  series, 
including  some  cases  operated  too  late,  with  no  real  chance  of 
permanent  rehef .  It  makes,  then,  a  much  too  unfavorable  showing 
of  the  actual  results  of  the  operation.  But  it  is  of  value  for  com- 
parison as  indicating  the  improvement  accompUshed  since  1886. 


Time. 

Patients 

Lost  Sight  of 

Patii 

ents  Dead 

Patients  Re-examined 

Before  Recurrence.        < 

3r  with  Recurrence. 

Without  Recurrence. 

3  raonlhs. 

5 

25 

122 

6  months. 

6 

20 

96 

9  months. 

5 

lO 

81 

12  months. 

2 

9 

70 

iS  months. 

lo 

S 

52 

2  years. 

14 

o 

38 

3  years- 

21 

o 

17 

4  years. 

10 

I 

6 

Treatment  of  Cancer  of  the  Cervix.  237 

From  the  preceding  figures  we  can  estimate  approximately  the 
proportion  of  survivals  and  relapses  in  one  hundred  patients  in  what 
might  be  called  the  initial  period  of  hysterectomy  (extending  up  to 
1886).  To  establish  this  i^roportion  it  is  right,  with  Hache,  to  con- 
sider all  the  patients  lost  sight  of  less  than  a  year  after  the  operation 
as  having  recurrence  immediately  after  the  last  examination  to 
which  they  submitted.  For  those  with  whom  the  period  of  observ- 
ation had  passed  a  year,  Hache  has  taken  as  having  recurrence, 
half  of  the  number  who  had  been  then  lost  sight  of.  The  results 
which  follow  ought  to  be  considered  as  the  most  pessimistic  inter- 
pretation of  the  statistics. 

Out  of  one  hundred  patients :  Twenty-three  succumbed  to  the 
operation ;  15  had  recurrence  in  tlxree  months,  13  from  thi'ee  to  six 
months  (28,  first  semestre) ;  13  had  recurrence  fi'om  six  to  twelve 
months  (13,  second  semestre) ;  10  had  recurrence  from  one  to  two 
years  (10,  second  year) ;  26  are  still  well  at  the  end  of  two  years. 

In  seeking  what  proportion  of  surviving  patients  have  recurrence, 
Hache  finds  that  the  chances  of  recurrence  remain  about  equal 
during  the  first  two  trimestres,  then  gradually  decrease.  This  result 
is  especially  due  to  incomplete  operations  and  to  immediate  growth 
of  a  neoplasm  that  has  been  simply  resected.  There  is  also  another 
factor,  the  galloping  character  of  some  cancers,  priiieipally  in  young 
womeli. 

An  important  and  more  recent  document  is  given  to  us  by  A. 
Martin,  in  the  series  reported  by  him,  comprismg  the  experience 
of  some  German  gynecologists  up  to  the  end  of  1886.  These  have 
been  the  results  as  regards  survival  mtbout  recurrence.  They  came 
back  after  the  following  time  : 


Recurrence 

Leopold,  out  of 

Schroeder,  out  of 

Fritsch,  out  of        Martin,  out  of 

at  the  end  of; 

36  Operations. 

62  Operations. 

53  Operations 

56  Operations. 

I  year. 

16 

20 

17 

35 

iJ4  years. 

9 

10 

17 

32 

2  years. 

5 

7 

7 

25 

3  years. 

2 

4 

2 

20 

4  years. 

2 

4 

2 

25 

5  years. 

2 

4 

2 

3 

6  years. 

2 

4 

2 

2 

These  figures  give  the  following  percentages :  Recurrence  at  the 
end  of  one  year,  42.30  per  100 ;  one  and  a  half  years,  32.90 ;  two 
years,  21.15 ;  three  years,  13.41 ;  4  years,  2.40. 

The  most  important  series  which  has  been  recently  ]3ublished  is 
that  of  Leopold,  of  eighty  vagural  hysterectomies  for  cancer,  of 
which  only  four  succumbed  to  the  operation.  It  comprises  his 
experience  in  this  particular  five  and  a  half  years.  Out  of  seventy- 
six  women  cured  fourteen  have  since  died,  among  them  only  ten 
from  recurrence  of  cancer,  the  others  from  other  causes.  Out  of 
the  sixty-two  surviving,  only  three  had  recurrence,  the  others 
remaining  cured  for  variable  times,  as  shown  in  this  table.     It 


238  Treatment  of  Cancer  of  the  Cervix. 

is  seen  here  that  twenty-seven  patients  remained  without  recur- 
rence for  two  years  and  over,  out  of  eighty  operations.  Still  it  is 
just  to  reduce  these  figiires  to  seventy-six  hy  taking  out  the  four 
women  who  died  fi"om  accidental  diseases. 

Out  of  seventy-six  patients  re-examined  after  cure  there  remain 
without  recmTence : 


S'A  years, 

I 

3}4  years. 

2^  years,              2 

5'X  years 

2 

3'A  years. 

6 

2      years,              3 

4X  years, 

2 

3      years. 

2 

I'X  years,              3 

3^  years 

J 

2J^  years, 

3 

I'X  years,              3 

2J4  years, 

2 

Between  1  year 
and  3  months,  4 

Hofmeier,  arier  Scm'oeder's  operations,  at  the  end  of  two  years 
gave  24  per  cent  as  representing  the  portion  of  complete  cures. 

It  is  interesting  to  know  the  results  after  partial  operations  (iiifra- 
and  supravaginal)  to  he  ahle  to  compare  them  with  those  of  total 
extirpation  of  the  uterus.  However,  the  comparison  between  these 
results  would  be  just  only  if  it  could  be  applied  to  two  series  of 
patients,  exactly  similar  and  aifected  to  the  same  extent.  In  this 
view  the  value  of  these  statistics  may  be  questioned. 

The  following  table  unites  in  comparative  results  the  statistics 
from  Schroeder's  cKnic  from  1878  to  1886 : 

,      ,  ,    r  f  Op.  partial,  49  cured  out  of  114  operations,  51.0  per  pent. 

At  the  ena  01   l  year.  |  ^^^^   ^^^^j^  ^^  ^^^^^  ^^^  ^^   _^g  operations,  63.6  per  cent. 

,  J     ,  f  Op.  partial,  38  cured  out  of  102  operations.  46.0  per  cent. 

At  the  end  ot  2  years.  |  ^^^^_  ^^^^j^    ^  ^^^^^  ^^^  ^C    ^^  operations,  24.0  per  cent. 

.      ,  If-         .    /  Op.  partial,  24  cured  out  of    76  operations,  42.0  per  cent. 

-"  ^        '  \  Hyst   total,    6  cured  out  of    31  operations,  26.0  per  cent. 

At  the  end  of  i  years  /  °P-  ?=""'''''■  '9  '="''ed  «"'  °^    59  operations,  41.3  per  cent. 
^  ■'        ■  \  Hyst.  total,    o  cured  out  of    iS  operations,    0.0  per  cent. 

The  results  obtained  by  Vemeuil  are  not  less  remarkable.  In 
infravaginal  amputation  of  the  cervix  with  the  ecraseur  he  had,  out 
of  twenty-one  successful  operations,  nine  with  early  recurrence.  In 
six  out  of  these  nine  cases,  examination  of  the  section  removed 
showed  that  the  ablation  was  not  complete.  Twelve  others  remained 
without  return;  in  two,  until  death,  after  seventeen  months  and 
after  seven  years ;  in  five,  until  the  patients  were  lost  sight  of,  on 
the  average,  three  years  after  the  operation.  In  two,  the  disease 
returned  after  three  years  of  apparent  cure,  and  in  three,  it  returned 
after  the  patients  had  been  in  actual  good  health  for  three  months, 
seventeen  mouths  and  five  years  respectively  In  contrast  with 
these  cases  cited  in  favor  of  partial  amputation  Martin's  results 
should  be  mentioned.  Out  of  twenty-eight  patients  only  two 
remained  without  return.  Since  this  series  he  has  adopted  early 
hysterectomy  and  the  duration  of  the  cures  has  considerably 
increased. 

Quite  recently  surgery  has  striven  to  open  new  ways  of  reaching 
the  pelvic    cavity.     Otto    Zuckerkandl    has  proposed   a  perinaeal 


Treatment  of  Cancer  of  the  Cervix.  239 

opening,  by  a  transverse  incision  made  so  as  to  give  all  the  space 
between  the  ischiatic  tuberosities,  in  place  of  being  limited  by  the 
walls  of  the  vagina.  Frommel  has  put  this  procedure  into  execution 
with  success.  On  the  contrary,  Sanger,  after  repeating  the  operation 
on  the  cadaver,  has  completely  rejected  it. 

The  parasacral  and  pararectal  incision  of  E.  Zuckerkandl  and  of 
Wolfler,  gives,  according  to  these  authors,  sufficient  room  for 
hysterectomy  in  difficult  cases.  It  consists  in  a  deep  incision  made 
either  to  the  right  of  the  sacrum  (Wolfler),  or  to  the  left  (Zucker- 
kandl). Wolfler  begins  this  incision  a  little  above  the  articulation 
of  the  sacrum  and  coccyx,  at  one  or  two  centimetres  outside  this 
point,  and  carries  it  downward,  with  a  shght  external  concavity 
corresponding  to  the  ischiatic  tuberosity,  to  within  two  or  three 
centimetres  of  the  fourchette.  The  ischio-rectal  fossa  is  thus 
entered  from  below.  The  gluteus  maximus  is  resected  (Wolfler 
then  extirpates  the  coccyx,  while  Zuckerkandl  leaves  it)  as  well  as 
the  saero-sciatic  ligaments.  The  levator  ani  is  incised  and  the 
rectum  is  detached  from  the  vagina.  Finally  the  culs-de-sac  of  this 
canal  are  opened  and  hysterectomy  is  proceeded  with  according  to 
the  rule  I  have  given.  The  operation  is  terminated  by  exact 
occlusion  of  the  peritonaeum  and  of  the  vagina  and  drainage  of  the 
parasacral  wound  which  has  been  somewhat  narrowed  by  sutures. 
Wolfler  has  used  this  method  on  the  living  for  extirpation  of  the 
rectum  and  for  that  of  the  uterus,  while  Zuckerkandl  has  confined 
himself  to  experiments  on  the  cadaver. 

Still  more  bold  and  more  rational  appears  the  application  to 
gynaecology  of  the  preliminary  "operation  devised  first  by  Kraske  to 
reach  the  cancerous  rectum.  It  consists  in  the  extirpation  not  only 
of  the  coccyx  but  also  of  the  inferior  part  of  the  sacrum  so  as  to 
create  a  very  large  opening.  The  patient  is  placed  in  the  right- 
lateral  decubitus.  Then  starting  from  the  point  of  the  coccyx  an 
incision  is  made  along  the  side  of  this  bone,  ascending  to  about  ten 
centimetres,  finally  curving  outward  and  terminating  toward  the 
middle  of  the  sacro-illiac  symphysis  (Fig.  114).  The  coccyx  is  extii'- 
pated  and  after  the  lower  part  of  the  sacrum  has  been  disengaged 
it  is  resected  with  a  strong  cutting  forceps,  first  laterally,  then,  if 
necessary,  transversely.  This  section  may  be  carried  to  just  below 
the  thu-d  sacral  foramen,  to  give  sufficient  space,  without  wounding 
any  important  nervous  branch  (Fig  114,  B).  The  rectum  is  then 
pushed  to  one  side  and  Douglas'  cul-de-sac  is  entered  by  incising  the 
peritonaeum.  Thus  is  obtained  an  enormous  space  (Fig.  115). 
Hochenegg  has  published  the  first  operations  on  the  living,  after 
Kraske's  method.  One  was  made  by  Gersuny,  who  was  able,  in 
this  way,  to  extirpate  a  voluminous  uterus  mth  a  cancerous  ganglion 
in  the  subperitonaeal  cellular  tissue ;  the  other  was  made  by 
Hochenegg  himself,  in  which  he  removed,  at  the  same  time,  the 


240 


Tiratmeiit  of  Cancer  of  the  Cervi-x. 


uterus  and  an  ovarian  eysf  as  large  as  the  fist.     Both  cases  were 
successful,  but  an  intestmal  fistula  resulted  in  the  second  case. 


Fig.  114. 


-Sacral  hysterectomy.     A.   Line  of  incision,  the  dotted  line  marks 
the  axis  of  the  body.     B.  Section  of  the  sacrum. 


Hegar  has  inaugurated  a  modification  of  this  method.  He  does 
not  extu-pate  the  bones  but  only  makes  section  and  temporai-y 
depression  of  the  coccyx  and     "  the  inferior  jjart  of  the  sacnini. 

When  the  hysterectomy  is  com- 
pleted he  replaces  the  section 
containing  the  bones.  Hoche- 
uegg  recommends  detachment 
of  the  vaginal  culs-de-sac  only 
after  ha-sing  closed  the  perito- 
neal wound  with  sutures,  in  this 
way  avoiding  possilile  infection 
from  the  cancer.  Wound  of  the 
rectum  constitutes  one  of  the 
dangers  of  the  operation  and 
wUl  necessitate  immediate  su- 
tui'e.  The  ureter,  also,  may  be 
divided.  After  sutuilng  the  fun- 
dus of  the  wound,  first  closing 
the  peritoucPuni,  then  the  vagina,  the  external  wound  will  be  closed, 
always  leading  an  opening  large  enough  to  permit  drainage  and 
antiseptic  tamponnemeut  of  the  cavity.  The  tampon  may  be  left  in 
place  six  to  eight  days,  then  renewed  and  reduced  in  bulk  in  pro- 
portion as  the  cavity  closes.  It  is  dangerous  to  make  complete 
closure  without  leaving  space  for  the  exit  of  the  oozing  hquids. 

The  facility  with  wliich  extirpation  and  control  of  hemorrhage 
may  be  accompKshed  by  this  method  is  incomparable.      It  is  a 


Fig.  115. — Sacral  hysterectomy.     Open- 
ing obtained  by  the  preliminary  operation. 


Treatment  of  Cancer  of  the  Cervix.  241 

valuable  resource  for  cases  where  the  uterus  is  too  voluminous  or 
the  vagina  too  narrow.  But  tliis  new  technical  facility  does  not  alter 
the  surgical  limits  that  I  have  assigned  to  total  hysterectomy.  When- 
ever cancer  has  extended  beyond  the  limits  of  the  uterus  no  attempt 
at  total  extirpation  should  be  made. 

IV.  Cancer  not  limited  to  the  cervix  with  certainty  or  suspicion  of 
deeper  propagation. — When  examination  of  the  mobility  of  the  uterus 
shows  that  there  is  difficulty  in  depressing  the  organ,  and  when 
bimanual  palpation  has  shown  the  existence  of  tumefaction  and  a 
pecuHar  dough-like  condition  at  the  sides  of  the  organ,  two 
hypotheses  are  possible  :  perimetritis,  with  adhesions ;  propagation 
of  the  cancer  to  the  pelvic  tissues  and  to  the  broad  ligaments.  In 
the  first  case  the  operation  may  be  difficult  and  even  dangerous  (for 
there  may  exist  purulent  foci) ;  in  the  second  case  it  is  dangerous 
and  useless.  Better  then  to  abstain,  however  great  may  be  the 
advantage  offered  by  the  sacral  method.  The  gravity  of  operative 
prognosis  is  doubled  in  cancer  with  extension.  The  term  palliative 
hysterectomy  has  been  wrongly  applied  to  ablation  of  the  uterus 
in  the  midst  of  cancerous  tissue.  This  is  a  lamentable  abuse  of 
scientific  language  by  seeming  to  justify  an  operation  in  a  case 
where  it  is  formally  contra-indicated.  An  operation  of  this  kind  is 
a  much  less  efficacious  palliative  than  simple  curetting  followed  by 
cauterization. 

V.  Cancer  of  the  cervix  having  invaded  the  vagina,  primarily  or 
secondarily. — This  invasion  is,  to  me,  a  formal  contra-indication  for 
radical  operation.  It  is  the  index  of  the  propagation  of  an  advanced 
cancer,  which  has  probably  already  infected  the  lymphatics,  or  it 
may  be  the  result  of  the  vaginal  form  of  cancer  of  the  cervix,  which 
has  an  uncontrollable  tendency  to  extend  to  the  vagina  and  to  recur 
in  the  same  place.  EationaUy,  then,  it  is  the  vagina  rather  than 
the  uterus  that  should  be  removed.  Here  again,  curetting  and 
cauterization  are  the  best  palliative  measures. 

VI.  Cancer  of  the  cervix  propagated  not  only  to  the  vagina  hut  also 
to  the  bladder  and  the  rectum. — In  spite  of  the  advice  of  some  dis- 
tinguished surgeons,  to  attempt  in  these  conditions  a  curative  oper- 
ation by  removing  the  uterus  and  the  invaded  portions  of  the 
rectum  and  bladder,  appears  to  me  a  serious  mistake.  Certainly, 
the  operation  is  feasible  and  may  succeed  immediately,  but  the 
recurrence  is  fatal  after  a  brief  delay,  for  a  cancer  thus  advanced 
has  already  surely  infected  the  lymphatics.  Finally,  the  graxdty  of 
the  hysterectomy  being  considerably  augmented  in  such  cases,  we 
may  ask  if  it  be  wise  to  expose  the  patients  to  so  grave  dangers  for 
so  uncertain  a  gain.  In  the  last  tlu-ee  categories  that  I  have  passed 
in  review,  the  attention  should  be  addressed  to  a  palliative  operation 
capable  of  suppressing  the  two  great  causes  of  the  weakness  of  the 
patients — haemorrhage  and  fetid  oozing.     To  this  end,  it  is  necessary 


242  Treatment  of  Cancer  of  the  Cervix. 

to  destroy  the  fungosities  rapidly.  The  instrument  t(j  be  used  is 
the  curette,  and  more  especially  the  sharp  curette.  The  large  fungi 
are  quickly  scooped  out  with  a  large  instiiimeut  aud  then  with  a 
smaller  one  the  cavities  are  scraped  out.  This  procedure,  however, 
must  be  made  with  gi-eat  caution  in  dangerous  regions  and  notably 
in  the  anterior  cul-de-sac  (bladder,  ureters).  In  penetrating  into 
the  uterus  care  wiU  be  taken  to  attack  the  surface  obliquely,  and  not 
perpendicularly,  to  avoid  perforations. 

After  cleansing  the  surfaces,  Martin  does  not  hesitate  to  reunite 
the  freshened  parts  to  induce  primary  union.  It  seems  that  the 
cases  favorable  to  the  application  of  this  method  are  very  rare,  and 
that  it  is  more  liable  to  do  harm  than  good.  I  prefer  to  foUow  the 
curetting  with  cauterization  with  the  actual  cautery,  as  by  its  radi- 
ation it  attacks  the  neoplastic  invasions  and  destroys  their  vitahty 
in  the  midst  of  the  more  resisting  living  tissues.  This  treatment 
should  be  repeated  at  intervals  of  some  weeks  or  months.  By 
operating  rapidly,  after  painting  ^\\ih.  cocaine,  and  imder  a  con- 
tinued cold  ii'rigation,  anaesthesia  can  be  omitted.  After  the 
curetting,  a  tampon  of  iodoform  gauze  is  placed  in  the  cavity 
produced  by  the  scooping  aud  renewed  at  the  end  of  two  days. 
Injections  of  sublimate  solution,  1-5000,  appear  preferable  to  all 
others.  As  soon  as  the  granulations  in  the  fundus  of  the  vagina 
begin  to  secrete  with  some  abundance,  I  apply  a  small  disk-like 
tampon,  soaked  in  a  one-tenth  solution  of  chloride  of  zinc,  fixed  in 
place  and  isolated  by  a  larger  tampon  of  iodoform  gauze  soaked  in 
a  solution  of  bicarbonate  of  soda.  Below  this  is  made  a  complete 
tamponnement  of  the  vagina,  to  avoid  displacement.  This  di-essing 
may  be  removed  every  two  days  aud  should  be  preceded  each  time 
by  a  copious  sublimate  douche. 

Potential  cauterization. — Various  caustic  agents  have  been  advised 
but  the  very  numerous  accidents  that  have  followed  their  use  have 
caused  the  majority  of  surgeons  to  abandon  them. 

As  a  disinfecting  injection,  in  very  fetid  cancers,  permanganate 
of  potash  solutions,  ten  or  twenty  to  one  thousand,  or  more  or  less 
dilute  preparations  of  Labarraque's  solution  are  useful.  Haemor- 
rhages may  be  much  diminished  by  tampons  of  gauze  or  cotton, 
which  are  dipped  m  perchloride  of  iron,  then  dried  and  powdered 
with  iodoform.  The  actual  cautery  is  the  most  efficacious.  Ergot 
is  without  efifect  and  the  same  may  be  said  of  digitalis. 

The  erythema  of  the  ^•^llva  will  yield  to  scrupulous  cleanliness, 
frequent  sitz-baths,  lotions  of  acetate  of  lead,  and  to  an  ointment 
of  vaseline  to  protect  the  parts  against  the  vaginal  oozing. 

The  gastric  phenomena  may  be  ti'eated  with  tonics  and  bitters. 
If  they  are  associated  with  renal  lesions  a  milk  diet  should  be  pre- 
scribed.   .\gainst  repeated  vomiting  of  uraemic  origin,  Winkler  finds 


Treatment  of  Cancer  of  the  Cervix.  243 

benefit  from  the  administration  of  a  drop  of  a  tincture  of  iodine  in 
water  before  each  meal.  Constipation  should  be  carefully  corrected 
as  it  causes  metrorrhagia  by  the  efforts  it  demands.  The  pains  are 
rarely  reheved  by  surgical  interference,  but  injections  and  frequent 
dressings  diminish  them  sensibly.  Moi'phine  can  not  be  refused 
condemned  patients  without  cruelty,  but  its  use  should  be  as  limited 
as  possible  to  avoid  impairment  of  the  digestive  functions  and 
depression  of  the  strength.  Some  specifics  have  been  praised : 
eonium  only  aggravates  the  gastric  troubles ;  condurango  (in 
decoction,  fifteen  grammes  to  two  hundred  grammes  of  water)  only 
acts  as  a  stomacliic  ;  chian  turpentine  (0.5  gm.  to  1  gm.,  in  pills) 
appears  to  have  no  harmful  action,  though  its  therapeutic  power  is 
not  yet  demonstrated. 

Cancer  of  the  cervix  complicating  pregnancy . — It  is  impossible  in  a 
woman  affected  with  cancer  of  the  uterus  to  recognize  pregnancy 
before  the  fourth  month,  for  the  enlargement  of  the  body  of  the 
organ  can  be  legitimately  attributed  to  an  extension  of  the  neoplasm. 
If  a  diagnosis  could  be  made  at  this  early  period,  would  this 
knowledge  modify  the  treatment  ?  I  think  not.  What  we  know  of 
the  unfavorable  action  of  pregnancy  on  the  evolution  and  of  the 
great  probabihty  of  abortion  perfectly  legitimizes  hysterectomy 
every  time  that  it  is  applicable  to  the  gravid  uterus.  For  this  it  is 
necessary:  1.  That  the  cancer  be  limited  to  the  utems ;  2.  That 
the  volume  of  the  uterus  permit  vaginal  extraction.  The  operation 
is  then  remarkably  easy  in  consequence  of  the  laxity  of  the  tissues. 
It  is  infinitely  preferable  to  infra-  or  supravaginal  amputation  of 
the  cervix,  as  when  this  has  been  done  abortion  has  resulted  in  most 
cases  and  quick  recurrence  has  followed.  If  the  cancer  has  invaded 
the  surrounding  tissues,  it  is  necessary  to  distinguish  two  classes  of 
cases.  If  the  cervix  is  very  hard  atid  undilatable,  abortion  should 
be  induced  and  followed  by  the  palliative  treatment  (curetting  and 
cauterization).  If  the  cervix  is  fungoid  but  extensible,  all  its  cir- 
cumference not  being  invaded,  it  is  better  to  wait  and  to  induce 
abortion  only  in  case  the  weakening  of  the  foetal  heart-sounds  give 
reason  to  fear  imminent  death. 

When  delivery  is  difficult  the  physician  should  have  recourse, 
according  to  circumstances,  to  forceps,  or  to  version,  or  as  a  last 
resort  to  Caesarian  section.  A  livuig  infant  should  not  be  sacrificed 
to  a  condemned  mother  by  making  a  craniotomy.  Finally  it  is 
necessary  to  note  those  rare  cases  where  the  cancer  is  still  limited, 
but  the  uterus  is  too  large  to  attack  by  vaginal  hysterectomy 
before  having  been  evacuated.  The  following  are  the  operations 
to  which  one  can  turn  according  to  the  circumstances  :  (a).  Induced 
abortion,  followed  by  hysterectomy  at  the  end  of  a  few  days ;  (b) . 
Caesarian  operation,  followed  later  by  colpohysterectomy ;  (c).  Total 


244 


Cancer  of  the  Cm-jJus  Uteri. 


extirpation  of  the  gravid  uterus  by  laparotomy  combined  with 
vaginal  dissectiou ;  (d).  Sacral  hysterectomy  (after  resection  of  the 
coccyx  and  of  a  part  of  the  sacrum  if  necessary). 

Cancer  of  cervix  complicated  with  ajibroid. — If  the  fibroid  be  very 
large  and  constitute  an  absolute  obstacle 
to  vaginal  hysterectomy  the  only  choice 
hes  between  abdominal  hysterectomy, 
extii-pation  by  the  sacral  operation,  and 
curetting  followed  by  cauterization.  It 
is  one  or  the  other  of  the  last  two  that  I 
would  follow,  as  the  dangers  of  abdo- 
minal hysterectomy  are  to  then  be 
feared  If,  on  the  contrary,  the  fibroid 
be  small,  vaginal  hysterectomy  should 
be  made.  I  have  succeeded  -ndth  some 
difficulty  in  a  case  where  there  was  a 
subperitons'al  fibroid  as  large  as  a  fist. 
Cancer  of  the  cervix  complicated  with  cyst  of  the  ovarii. — If  the  cancer 
of  the  cervix  justifies  hysterectomy,  should  this  operation  be  made 
before  or  after  ovariotomy,  or  in  two  sittings,  or  in  a  single  one  ? 
I  believe  the  cancer  shoiild  be  treated  first,  as  the  most  menacing 
affection,  a  radical  extirpation  tlu-ough  the  vagina,  and  then,  after 
recovery,  ovariotomy.  If,  on  the  contrary,  only  a  palliative  treat- 
ment is  indicated  for  the  cancer  on  account  of  its  propagation, 
ovariotomy  should  not  be  thought  of,  the  patient  being  condemned 
to  only  a  brief  delay. 


Fig.  ii6. — Sacral  hysterectomy. 
Reunion  and  drainage. 


CHAPTER  XVI. 


CANCER   OF   THE   CORPUS  UTERI. 

Adenoma  of  the  uterus. — A  cei-tain  confusion  reigns  among 
authors  relative  to  adenoma  of  the  uterus.  Some  authors  term 
typical  adenoma,  that  which  I  described  in  a  preceding  chapter, 
as  glandular  endometritis,  and  atypical  adenoma,  or  malignant, 
the  first  phase  of  the  degeneration  of  the  mucosa  into  epithelioma. 
This  divergence  relates  to  the  fact  that  wliile  some  make  a  division 
exclusively  from  an  anatomical  point  of  %iew,  holding  especially  to 
pathological  distinctions  and  histological  denominations,  I  have 
made  the  chnic  take  the  principal  part  in  the  division.  I  will 
return,  then,  purely  and  simply  for  that  which  concerns  benign 


Cancer  of  the  Corpus  Uteri. 


245 


adenoma,  to  the  chapter  on  metritis,  and  the  chapter  on  ghxndular 
metritis  may  be  consulted  for  its  anatomo-pathological  description. 
I  will  refer  the  reader  in  like  manner  to  catarrhal  and  hsemorrhagic 
metritis  and  to  mucous  polypi  for  the  symptoms. 


Fig.  117. — ^Benign  adenoma  of  the  uterine  mucosa  (Wyder.). 


With  regard  to  malignant  adenoma,  it  is,  in  short,  the  initial 
process  of  cancer  of  the  mucosa.  If  it  is  desired  to  distinguish  it 
more  definitely  it  may  be  called  glandular  epithelioma,  adeno- 
carcinoma or  glandular  carcinoma  in  the  histological  description. 
It  is  sufficient  to  glance  at  the  two  following  illustrations  to  see  at 
once  the  great  difference  which  separates  the  benign  from  the 
malignant  form,  and  at  the  same  time  to  note  the  transitions  which 
permit  the  transformations  of  one  of  these  affections  into  the  other, 
so  that  the  lesion  beginning  as  a  slight  glandular  metritis  becomes 
a  glandular  metritis  of  a  more  marked  form  (typical  benign 
adenoma),  then,  by  degenerating,  an  atypical  malignant  adenoma, 
the  first  stage  of  cancer.  In  the  so-called  benign  adenoma  (Fig.  117) 
the  glandular  proliferation  is  absolutely  typical.  Solid  epithelial 
collections  are  not  met  in  any  part  of  the  tubes.  The  cylindt'ical 
epithelium  is  disposed  in  a  single  layer.  Between  the  glandulnr 
tubes  there  is  still  certain  quantity  of  normal  interglandular  tissue. 
The  glandular  layer  and  the  muscular  layer  are  well  limited.  The 
glands  have  no  tendency  to  penetrate  into  the  muscular  parenchyma 


216 


Cancer  of  the  Corpus  Uteri. 


and  destroy  it.  In  malignant  adenoma  (Fig.  118),  contrary  to 
that  seen  in  the  preceding  case,  the  proliferation  of  the  glands  is 
atypical.  Furnished  with  a  simple  covering  of  epithelial  cylindrical 
cells,  they  are  coUected  in  glomeruli.  The  fibrous  substratum  has 
almost  entirely  disappeared  and  the  glands  even  he  against  each 
other  in  Tarious  points.  There  is  no  limit  between  the  glands  and 
the  uterine  muscle.  With  regard  to  symptoms,  prognosis  and 
treatment,  malignant  adenoma  is  identical  with  cancer  of  the  body 
of  the  uterus. 


Fig.  IiS. — Malignant  adenoma  of  the  uterine  mucosa  (Ruge  and  Veil). 
(Beginning  glandular  epithelioma). 

Cancer  of  the  corpus  uteri. — Cancer  of  the  body  of  the  uterus  pre- 
sents various  anatomical  forms  which  respond  to  some  quite  sharply 
defined  chuical  types,  as  follows: 

A. 


Epithelioma  ^  French  authors)  or 
I.  Cancer  of  the  mucosa,  i  carcinoma  (German  authors). 

(  B.  Sarcoma. 
II.  Cancer  of  the  parenchyma,  or  fibro-sarcoma. 


Primary  cancer  of  the  uterus  was  regarded  as  very  rare  until 
late  years.  Gallard  only  diagnosticated  two  cases  in  his  long  career 
and  Pichot,  in  1876,  could  only  collect  forty-four  cases  from  French 
and  Enghsh  authors.  This  is  because  the  older  gynaecologists  very 
rarely  used  explorative  dilatation,  and  explorative  curetting  stiU 
more  rarely.  To-day,  by  the  use  of  these  valuable  procedures,  it 
has  been  recognized  that  primaiy  cancer  of  the  uterine  mucosa  is 


Cancer  of  the  Cm'pus  Uteri. 


247 


much  more  frequent.  Gusserow  has  been  able  to  collect  one 
hundred  and  twenty-two  cases  from  late  statistics.  With  regard 
to  the  relative  frequence  of  cancer  of  the  cervix  and  that  of  the  body, 
t  occurs,  according  to  Szukitz,  in  the  proportion  of  four  hundred 
and  twenty  to  one.  But  more  recently  Schroeder,  out  of  eight 
hundred  and  twelve  cancers  of  the  uterus,  has  noted  twenty-eight 
primary  cancers  of  the  body  and  Schatz,  out  of  eighty  cases,  has 
aeen  tw«. 


Fig    1 19. — Epithelioma  of  the  uterine  mucosa;   circumscribed  form. 

I  will  describe  successively  the  tlu'ee  forms  of  primary  cancer  of 
the  body  of  the  uterus. 
I. — Epithelioma   (or  carcinoma)    of  the   m.ucosa. — The 

Germans  ordinarily  call  carcinoma  what  the  French  to-day  term 
epithelioma.  I  shall  use  these  two  terms  indifferently  as  indicating 
one  and  the  same  lesion.  It  could  almost  be  called  cancer  of  the 
menopause,  considering  its  special  frequence  at  this  period  of 
genital  life.  It  takes  its  origin  in  the  alterations  of  glandular  me- 
tritis, that  I  have  noted. 

Pathological  anatomy. — In  a  microscopic  point  of  view  two  varieties 
can  be  distinguished.  Sometimes  there  exists  a  diffuse  callous  growth 


248 


Cancer  of  tltc  Corpus  Uteri. 


Fig.  I20. — Epithelioma  of  the  uterine  mucosa.     Diffuse  form. 

Fig.  121. — Epithelioma  of  the  uterine  mucosa.  Difiuse  form,  with  circumscribed 
thickening,  a,  muscular  wall  of  the  uterus;  iS  ^,  section  of  the  neoplasm;  ^,  front 
view ;  a',  cervix  unaffected. 

over  the  whole  uterine  ca^■ity  (Figs.  120, 1'21).  Again,  there  is  an  iso- 
hxted  fungus,  with  more  or  less  extensive  base,  sometimes  polj^joid 
(Fig.  119).  It  must  he  noted  that  the  neoplasm  has  little  tendency 
to  invade  the  cervical  mucosa.  This  is  at  once  a  difficulty  in  the  way 
of  diagnosis  and  a  valuable  point  for  treatment.  The  uterine  wall, 
on  the  contrary,  is  destroyed  little  by  Uttle  and  eaten  away  by  rajiid 
invasion.  Metastatic  nuclei  form  in  various  parts  of  the  parenchyma, 
and  even  imder  the  peritonaeum.  Here  this  membrane  forms  pro- 
tective adhesions.  A  perforation  sometimes  causes  a  fatal  peri- 
tonitis or  an  abnormal  communication.  Metastatic  nuclei  are  also 
often  observed,  superficially  in  the  vagina,  and  deeply  in  the 
ovaries,  the  tubes,  etc. 

In  a  histological  point  of  ^•iew  they  are,  according  to  Cornil, 
tubular  and  lobulated  epitheliomata,- with  tubules  mostly  large  and 
anastomosing,  offering  the  latter  in  particular,  as  the  first  layer  of 
cells  implanted  on  the  tube  wall  is  regularly  cyHndrical.  These  are 
long  cells  with  deeply  stained  nuclei.  The  successive  layers  are 
formed  by  polyhedral  cehs,  sometimes  of  the  pavement  variety. 
The  most  internal  become  mucous,  ai'e  filled  with  granules,  and 
their  nuclei  are  often  atrophied.  On  examming  the  cells  with  a 
low  magnifying  power,  there  are  seen  luimerous  alveoli  with  thin 
walls  covered  with  cyHndrical  epithelial  cells  forming  several  layers. 
There  are  also  large  cavities  containing,  in  the  fresh  state,  a  mucous 
liquid  Mith  cells  in  suspension  (Fig.  12'2).     It  is  easy  to  account  for 


Cancer  of  the  Corpus  Uteri. 


249 


the  formation  of  these  cavities.  From  the  fibrous  wall  which 
surrounds  them,  capillary  vessels  penetrate  into  the  epitheUal 
layer.  These. vessels  in  the  epithelial  layer  take  on  a  papiUary  form. 
Some  tubes,  then,  that  were  primarily  narrow  are  thus  transformed 
into  large  cavities  with  granulating  walls.  Under  a  higher  magni- 
fying power  this  process  is  made  plainer  (Figs.  123,  124). 


Fig.  122. — Epithelioma  of  the  body  of  the  uterus  (120  diameters),  b  b,  lobules  of 
the  epithelioma ;  m,  lobules  showing  empty  spaces  which  are  sections  of  vessels  or 
cavities  filled  with  cells;  «,  small  alveoli  (Cornil). 

Aside  from  these  clearly  epithehal  lesions  there  are  found  almost 
constantly  the  alterations  of  simple  chronic  metritis.  It  is  thus 
necessary  to  examine  a  number  of  small  fragments  to  avoid  the  risk 
of  error.  The  great  quantity  of  cylindrical  cells,  in  these  tubular 
or  lobulated  formations,  distinguish  these  epitheliomata  of  the  cervix 
and  body  of  the  uterus  from  those  which  develop  in  the  skm.  They 
present,  in  fact,  a  special  form,  in  relation  to  the  elements  of  the 
mucous  membrane  in  which  they  develop.  At  an  advanced  period 
cancers  of  the  body  may  ulcerate.  In  some  cases  the  corporeal 
mucosa  remains  easily  recognizable,  its  epithelial  layers  are  pre- 
served, although  covered  by  migi-atory  cells,  the  glands  alone  are 
atrophied,  their  cylindrical  ceUs  being  small.  The  connective 
tissue  is  compromised,  compressed  and  tlnn.  In  other  parts  the 
mucosa  is  reduced  to  a  very  thin  layer  of  connective  tissue  covered 
by  a  single  row  of  cylindrical  cells  (Fig.  125).  Later,  the  muscular 
layers  are  infiltrated  by  the  neoplastic  growth.  There  may  also  be 
extension  to  the  tubes  and  ovaries.  0.  Piering  has  noted  a  unique 
case  of  pavement  epithelioma  of  the  body  of  the  uterus. 


260 


Cancer  of  the  Carpus  Uteri. 


'^j/oiiA 


y 


Fig.  123. — Epithelioma  of  the  body  of  the  uterus  (highly  magnified),  c,  connective 
tissue;  </,  glandular  cul-de-sac ;  y^ »!,  dilated  and  modified  glands;  a,  large  cavity 
(Comil). 


Fig.  124. — Primary  epithelioma  of  the  body  of  the  uterus  (300  diameters).  /. 
stratified  epithelium ;  c  c,  cells  in  karyokinesis :  /,  muscular  tissue  of  the  uterus 
(Comil). 

Symptoms. — Hivmoirhiige  is  the  primary  symptom  and,  as  .u 
cancer  of  the  cervix,  it  is  usually  accompanied  by  a  serous  flow, 
reddish,  and  of  a  sickening,  fetid  odor.  In  some  cases  small 
fragments  are  expelled  from  disintegrating  fungi.  The  pains  and 
the  other  functional  and  reflex  symptoms,  long  remain.  But  in 
proportion  as  the  disease  progi-esses,  the  pains  take  on  a  paroxysmal 
character  that  is  almost  pathognomonic.  These  crises  of  excruci- 
ating pain  are  wrongly  attrilmted,  by  Sehroeder,  to  uterine  con- 


Cancer  of  the  Corpus  Uteri. 


251 


tractions  endeavoring  to  relieve  the  organ  of  its  abnormal  contents. 
They  have  nothing  of  the  character  of  colic,  and  their  appearance 
at  regular  hours,  once  or  twice  a  day,  even  after  curetting  has 
destroyed  the  tumor,  prove  that  they  are  due  to  a  true  neuritis 
from  extension  along  the  nerves  of  the  disorganized  tissues. 


Fig.  125. — Mucosa  of  the  cervix  compressed  and  atrophied  by  a  cancer  developed 
in  its  deep  layers  (300  diameters),  e e,  epithelial  cells;  a,  migratory  cells;  b,  des- 
quamated epithelial  cells;  i,  connective  tissue;  v,  vessel;  g,  tubular  gland  (Cornil). 


Fig.  126  — Sarcomi  of  the  utenne  mucosa. 

Palpation  of  the  uterus  by  bimanual  exploration  demonstrates  the 
increase  in  volume.  This  may  even  attain  that  of  a  pregnancy  in 
the  fourth  month.  For  a  long  period  the  uterus  remains  mobile, 
but  later,  it  becomes  fixed  in  the  pelvis  in  consequence  of  adhesions. 
To  touch,  the  cervix  is  intact,  but  often  softened  and  a  little  opened, 
as  in  the  gravid  uterus.  The  sound  reveals  the  increase  in  the 
capacity  of  the  organ  and  the  presence  of  irregular  masses.     Some- 


252  Cancer  of  the  Corjnts  Uteri. 

times  suflicieut  dilatation  can  be  obtaiued  with  the  fiuger  to  permit 
it  to  feel  the  fungous  nature  of  the  uterine  cavity.  An  artificial 
dilatation  will  comprise  the  diagnosis.  It  is  better  to  make  this 
quickly  with  a  metallic  dilator  or  with  Hegar's  bougies,  so  as  not 
to  occlude  the  cervix  too  long  by  the  use  of  a  tent.  The  failure  in 
general  health  follows  the  phases  of  the  development  of  the  neoi)lasm 
and  ends  in  cachexia. 

DiacpiosU. — The  haemorrhages,  the  serous  oozings,  the  increase 
in  the  size  of  the  uterus  and  intrauterine  exploration  are  suificient 
elements  for  its  appreciation.  The  examinations  of  fragments 
removed  with  the  curette  sharply  define  the  diagnosis  between 
cancer  and  metritis  without  a  maUgnant  neoplasm.  In  the  same 
manner  distinction  will  be  made  between  carcinoma  and  sarcoma. 

There  are  some  cases,  however,  where  the  differentiation  from 
metritis,  even  with  histological  examination,  meets  with  great  diffi- 
culties. These  are  cases  where,  with  an  assemblage  of  common 
rational  symptoms,  in  particular  a  persistent  haemorrhage  that 
resists  curetting,  there  only  remain  its  resistance  to  therapeutic 
measures  and  the  examination  of  the  insignificant  fragments  that 
the  curette  removes.  Now,  if  the  histological  diagnosis  is  easy 
when  one  has  the  entire  utems  at  disposal,  it  is  quite  otherwise 
when  there  are  only  small  fragments  of  the  mucosa  for  sections. 
The  simple  glandular  hypertrophy  of  endometritis  may  then  be 
very  difficult  to  difi'erentiate  from  epithehoma,  especially  when,  in 
the  fragments  of  the  mucous  membrane,  the  whole  depth  of  the 
gland  cannot  be  examined.  It  may  thus  happen  that  we  will  be 
obliged  to  make  a  vaginal  hysterectomy  on  the  simple  diagnosis  of 
a  probal)ility  and  as  an  ulterior  resource  against  a  persistent 
metrorrhagia  which  menaces  life.  First,  however,  we  assure  our- 
selves by  examination  of  the  appendages  that  they  are  not  the 
origin  of  a  haemorrhagic  reflex.  From  a  section  of  the  uterus,  thus 
removed,  the  characteristic  lesions  of  epithelioma  have  sometimes 
been  determined,  when  examination  of  the  fragments,  furnished  by 
the  curette,  revealed  nothing  of  a  malignant  nature.  Martin  and 
Lohlein  have  cited  cases  of  this  kind  that  are  very  instructive. 

A  fibroid  in  the  process  of  decomposition  will  be  recognized,  in 
doubtful  cases,  by  the  histological  examination  of  the  fragments. 
The  presence  of  a  metastatic  nucleus  in  the  vagina  wiU  make  the 
nature  of  the  disease  evident. 

The  prognosis  is  grave;  however,  after  early  operation,  patients 
have,  in  some  cases,  Uved  for  many  years. 

Etiolofiy. — This  form  of  primary  cancer  of  the  corpus  uteri  is 
common  to  women  who  have  passed  the  menopause.  The  average 
age,  observed  by  Hofmeir,  is  fifty-four  years.  Out  of  thirty-one 
cases  of  maUguant  tumors,  comprising  the  different  varieties  of 
cancer  of  the  cervix  removed  by  Piehot,  only  nine  were  under  fifty 


Cancer  of  the  Corpus  Uteri. 


253 


years  of  age.  In  one  case  there  was  a  manifest  hereditary  influence. 
Nulliparous  women  are  very  much  more  frequently  affected  than  is 
true  of  cancer  of  the  cervix.  Twenty- one  out  of  one  hundred 
patients,  observed  by  Hofmeier,  had  not  had  children. 

II. — Diffuse  sarcoma  of  the  mucosa. — According  to  Vir- 
chow,  "  diffuse  sarcoma  "  is  a  thickening  of  the  mucous  membrane 
by  the  proliferation  of  round  or  fusiform  cells  which  infiltrate  the 
mucosa  and  determine  the  appearance  of  soft,  villous,  or  lobulated 
tumors,  having  an  encephaloid  aspect  and  reproducing  the  embry- 
onic type  of  connective  tissue.  This  disease  is  common  to  young 
women. 


Diffuse  sarcoma  of  the  uterine  mucosa  (Wyder) 


Pathological  anatomy. — I  will  not  dilate  upon  the  well-known  histo- 
logical characters  of  the  sarcomata  (Fig.  127).  Sometimes  the 
union  of  the  histological  characters  of  sarcoma  and  of  carcinoma 
has  been  noted  in  the  form  of  mixed  tumors,  triie  carcino-sarco- 
mata  (Klebs).  When  the  sarcoma  forms  a  pedunculated  tumor,  it 
may  engage  in  the  cervix,  as  a  polypus.  Its  ulceration  and  its 
disintegration  are  less  rapid  than  the  same  processes  in  epithe- 
lioma. But  when  they  commence,  sarcoma  may  also  destroy  the 
uterine  parenchyma. 

Symx)toms  and  diafinosis. — The  symptoms  resemble,  in  more  than 
one  point,  those  of  the  preceding  form ;  haemorrhages,  serous 
discharge,  increase  in  the  volume  of  the  uterus,  cervix  intact. 
Introduction  of  the  finger  after  dilatation  permits  recognition  of 
the  neoplasm.  The  clinical  characteristics  which  distinguish  sar- 
coma from  epithelioma  are,  especially :  lessened  degree  of  fetidity 
of  the  flow  during  the  early  period,  late  ulceration,  diminished 
amount  of  dilatation  of  the  cervix,  possible  appearance  of  a  polypoid 
tumor  pushing  tlnough  the  cervix,  descending  into  the  vagina  and 
sometimes  causing  inversion  of  the  uterus. 

The  prognosis  is  of  the  greatest  gravity.  The  return  of  sarcoma 
is  fatal  even  after  an  early  operation  (Freund). 


254  Cancer  of  the  Corpus  Uteri. 

Etiology.  —  One  of  the  most  remarkable  characteristics  of  this 
neoplasm,  which  differentiates  it  from  epithehoma,  is  the  age  of 
the  patients  attacked.  There  are  numerous  cases  among  women 
of  less  than  twenty  years.  Zweifel  has  reported  the  observation  of 
a  hysterectomy  for  uterine  sarcoma  in  a  girl  of  thii-teen  years  of 
age.  It  especially  attacks  nuUiparous  women.  It  appears  to  have, 
as  a  fii'st  stage,  an  interstitial  e-ndometritis. 

III. — Fibro-sarcomatous  tumors. — Pathological  anatomy. — 
These  growths,  from  a  clinical  point  of  view,  might  be  called 
malignant  fibroid  tumors.  Like  benign  fibroid  growths,  they  may 
be  submucous,  subperitonaeal  or  interstitial.  They  also  arise  in 
the  uterine  parenchyma  but,  as  an  important  fact,  in  place  of 
constituting  masses  more  or  less  isolated  by  a  capsule,  they  are 
deeply  rooted.  On  section,  theii-  surface  is  pale,  their  consistence 
soft  and  homogeneous.  When  they  are  pedunculated,  their  pedicle 
is  of  fibrous  structm-e  and  it  is  evident  that  they  proceed  from  the 
degeneration  of  a  fibro-muscular  polypus.  The  vestiges  of  a 
primary  benign  structure  are  often  recognized  in  sessile  tumors, 
but  in  others  the  characteristic  tissue  of  sarcoma  (accumulation  of 
round  ceUs,  and,  more  rarely,  fusiform)  is  only  traversed  by  rare 
fasciculi  of  connective  tissue.  It  is  extremely  probable  that  a  fibro- 
sarcoma has  always  had  for  a  matricular  tissue  a  iibro-myoma. 
Distant  metastatic  nuclei  have  been  observed  in  the  vagina,  the 
peritonaeum,  the  lungs,  the  Hver  and  the  vertebrae.  Transformations 
of  fibro-sarcoma  into  myxo-sarcoma,  into  cysto-sarcoma  and  other 
mixed  tumors  ai-e  rare. 

Symptoms. — In  the  beginning  there  is  nothing  to  distinguish  a 
fibro-sarcoma  from  a  benign  fibroid.  There  occur  haemorrhages  in 
the  form  of  menorrhagia  or  of  metrorrhagia,  serous  discharge,  an 
odorless  hydrorrhcea,  some  pain,  and  increase  in  the  volume  of  the 
uterus.  The  physical  phenomena  are  those  of  a  non-ulcerating 
tumor,  that  can  be  felt  after  dilatation,  if  it  is  submucous.  Later, 
ulceration  of  the  neoplasm  makes  a  change.  The  haemorrhages 
become  an  almost  continual  oozing  of  blood.  The  leucorrhoea  takes 
on  a  fetid  odor  and  contains  rice-like  debris  in  which  the  micro- 
scope reveals  the  presence  of  sarcomatous  tissue.  The  pains  are 
marked  and  assume  the  paroxysmal  character  spoken  of  in  carci- 
noma. On  local  examination  a  finger  introduced  into  the  intact 
but  dilated  cervix  may  feel  the  friable  mass  of  the  cancer,  some- 
times projecting  spontaneously  between  the  lips  of  the  cer\-ix.  The 
body  of  the  uterus  is  much  increased  in  volume.  It  is  sometimes 
retroverted  and  becomes  immobile  at  a  late  period.  Even  inversion 
of  the  uterus  has  been  noted  in  consequence  of  sarcoma. 

The  cachexia  becomes  more  and  more  marked.  This  second 
phase  is  often  preceded  by  a  passing  relief  due  to  extii-pation  of 
the  sarcoma,  which  has  been  mistaken  for  a  fibroid.     During  the 


Treatment  of  Cancer  of  the  Corpus  Uteri.  256 

operation  the  nature  of  the  tumor  will  be  suspected  from  its  complete 
fusion  with  the  contiguous  tissues,  making  enucleation  impossible. 
A  rapid  recurrence  leaves  no  doubt.  It  is  this  character  which  has 
given  to  this  tumor  the  name  "recurrent  fibroid." 

Diagnosis. — Suspected  fi-om  the  rational  and  general  symptoms 
its  diagnosis  will  be  assured  by  examination  of  the  tumor  with  the 
finger  introduced  deeply,  after  dilatation  if  necessary.  In  the 
early  period  the  diagnosis  wiU  be  in  doubt  only  between  sarcoma 
and  a  hsemorrhagic  metritis  or  a  fibroid  and  later  between  sarcoma 
and  a  sloughing  fibroid,  an  epithehoma  or  a  sarcoma  of  the  uterine 
mucosa.  Microscopical  examination,  after  explorative  ciiretting, 
will  be  of  valuable  assistance. 

The  prognosis,  always  serious,  is  of  variable  gravity.  Prompt 
return  is  especially  observed  among  young  subjects  and  in  tumors 
which  have  had  a  rapid  development.  The  total  duration  of  the 
disease  varies  between  four  months  (Frankenhauser's  case)  and  ten 
years  (Hegar).     The  average,  according  to  Eegi^aie,  is  three  years. 

^Etiology. — By  reuniting  the  cases  published  to  1885,  Gusserow 
has  compiled  a  statistical  table  showing  that  the  predisposition, 
created  by  the  menopause,  exists  here  as  for  all  the  other  malignant 
growths.  Out  of  seventy-five  cases  analyzed  by  the  same  author, 
as  regards  sterility  and  fecundity,  twenty-five  females  were  sterile 
(four  virgins).  These  figures  are  in  contrast  with  what  I  have  said 
on  the  predisposition  of  multiparas  to  cancer  of  the  cervix. 

Treatment  of  cancers  of  the  corpus  uteri. — There  is  no 
difference  to  estabhsh,  as  concerns  treatment,  between  the  various 
forms  of  cancer  of  the  corpus  uteri.  That  which  applies  to  epithe- 
lioma applies  as  well  to  sarcoma.  The  indications  are,  as  in 
cancer  of  the  cervix,  to  make  a  radical  operation  in  cases  where 
we  can  hope  to  remove  all  of  the  disease,  and  when  the  operation 
is  justified  by  the  benefits  to  be  derived  from  it.  In  the  contrary 
case,  to  confine  the  operation  to  palliative  measures. 

Vaginal  hysterectomy  is  the  treatment  by  choice.  It  should  be 
attempted  as  early  as  possible  to  avoid  excessive  development  of 
the  uterus.  In  fact,  Sehi-oeder  imposes,  as  a  rule,  the  removal  of 
the  uteras  thi'ough  the  vagina  only  when  the  organ  does  not  exceed 
the  size  of  the  fist.  This  hmit  could  be  passed  by  employing 
segmentation,  but  this  would  involve  great  danger  of  infection  in 
the  case  of  a  cancerous  uterus.  It  should  be  noted  that  the  vaginal 
operation  is  much  facilitated  by  the  presence  of  a  healthy  cervix. 
If  the  uterus  is  so  large  that  it  is  not  prudent  to  attempt  vaginal 
hysterectomy,  recourse  might  be  had  to  parasacral  hysterectomy, 
though  this  operation  is  too  new  to  permit  any  adequate  estimate 
of  its  value. 

At  present,  however,  when  the  uterus  is  too  voluminous  for 
extraction  through   the  vagina,   it  is   most  frequently  removed 


256  Treatment  of  Cancer  of  the  Corpus  Uteri. 

thi'ough  an  abdominal  intdsion.     Two  classes  of   cases   may  then 
present : 

1.  The  cervix  remains  healthy.  The  body  can  then  be  removed, 
leaving  the  cernx  as  a  jjedicle,  supravaginal  hysterectomy.  Un- 
fortunately in  most  cases  the  cervix  furnishes  so  short  a  stump  that 
it  cannot  be  fixed  outside  the  abdominal  wound.  It  will  then  be 
abandoned  in  the  abdomen,  after  being  sutured  according  to 
Schi-oeder's  method.  But  it  is  necessary  to  be  sure  that  the  cervix 
is  intact,  even  to  the  extent  of  curetting  and  cauterizing  the  mucosa 
of  the  stump.  Abdominal  hysterectomy  applied  to  cancer  of  the 
uterus  has  given  Schroeder  four  deaths  out  of  thirteen  patients,  or 
39.0  per  100.  Eapid  recurrence  appears,  a  priori,  very  much  to  be 
feared,  for  the  section  of  the  cervix  is  necessarily  carried  very  near 
the  diseased  tissues.  However,  out  of  eleven  patients  cured  by 
Schroeder,  only  tlu-ee  succiimbed  to  recurrence  in  the  course  of  the 
first  year ;  four  were  still  cured  after  two  years  and  one  after  five 
years.  In  his  last  edition  Schroeder  mentions  two  cures,  dating 
one  from  five  years,  the  other  from  seven,  which  evidently  belong 
to  the  same  series. 

2.  If,  the  uterus  being  very  large,  the  cervix  is  affected,  supra- 
vaginal hysterectomy  by  abdominal  section  is  no  longer  efficient, 
and  total  extirpation  by  laparotomy,  or  Freund's  operation,  must 
be  attempted.  The  typical  operation  of  Freund,  which  was  described 
in  his  first  memoirs,  is  now,  however,  not  practiced  without  the 
modification  that  Eydigier  proposed,  consisting  in  completely  free- 
ing the  cervix  on  the  vaginal  side  before  opening  the  abdouT^n. 
The  operation  thus  perfected  is  performed  as  follows  : 

The  patient  is  prepared  as  for  vaginal  hysterectomy.  The  first 
and  second  stages  of  that  operation  are  executed.  Then  an  iodoform 
tampon  is  placed  in  the  vagina  and  laparotomy  is  performed. 

Third  stage. — Opening  the  ahdomen. — The  incision  begins  at  the 
umbilicus  and  extends  to  a  finger's  breadth  above  the  pubes.  It  is 
well  to  place  a  provisional  suture  in  the  abdominal  walls  at  the 
inferior  angle  of  the  wound,  to  avoid  separating  the  structures.  If 
the  abdominal  wall  is  very  rigid,  one  or  both  recti  muscles  may  be 
divided  at  the  level  of  the  pubes.  Crede  has  advised  and  executed 
a  bold  procedure  to  admit  light.  He  has,  in  the  beginning  of  the 
operation,  practiced  resection  of  a  part  of  the  pelvic  wall.  The 
intestines,  which  mU  be  given  a  tendency  toward  the  diaphragm  by 
the  inclined  position  of  the  patient,  may  be  pushed  back  with 
sponges.  If  there  be  no  other  means  of  making  the  field  clear, 
evisceration  will  be  necessary,  keeping  the  intestinal  mass,  when 
outside  the  abdomen,  moist  and  warm  by  envelopiag  it  in  sponges 
frequently  renewed. 

Fourth  stage. — Ligature  and  section  of  the  broad  ligaments. — The 
uterus  is  grasped  with  the  volsella  and  strongly  drawn  upward. 


Treatment  of  Cancer  of  the  Corpus  Uteri.  257 

Freund  then  ligates  the  broad  ligaments  successively  in  three 
portions.  To  pass  the  inferior  thread,  which  controls  the  iiterine 
artery,  he  uses  a  needle  trocar.  But  since  the  operation  is  now  com- 
menced by  the  vagina  this  manoeuvre  is  very  much  simplified,  for 
the  uterine  vessels  are  tied  from  below.  These  preliminary  stages 
have,  besides,  the  enormous  advantage  of  more  certainly  avoiding 
the  ureters,  since  by  dissecting  out  the  cervix  and  drawing  it  down- 
ward they  are  disengaged  and  carried  upward.  It  is  also  possible 
to  perceive  them  after  opening  the  abdomen.  The  uterus,  after  be- 
ing drawn  out  to  a  convenient  distance,  is  detached,  '"  like  a  tumor." 
Previous  to  this  Bardenheuer  places  isolated  ligatures  on  the 
important  vessels  that  are  easily  recognized  in  the  broad  ligaments 
and  only  cuts  the  ligaments  after  the  ligating.  The  separation 
from  the  bladder  should  be  made  with  great  care  after  incision  of 
the  peritonseal  cul-de-sac.  The  ovaries  are  removed  in  young 
women. 

Fifth  stage. — Dressing. — We  should,  it  seems  to  me,  as  after 
eolpohysterectomy,  suture  the  stumps  of  the  broad  ligaments  to  the 
edges  of  the  vaginal  incision,  narrowed  by  two  sutures,  make  the 
peritonseal  toilet,  close  the  abdominal  wound  and  place  iodoform 
gauze  in  Douglas'  cul-de-sac  and  in  the  vagina.  Freund  prefers 
to  close  the  vaginal  wound,  carefully  reuniting  the  peritonaeum 
above  it  by  sutures.  He  brings  the  ligature  threads  through  the 
vagina  and  by  exercising  a  stronger  traction  on  the  ligatures  of  the 
superior  part  of  the  broad  ligaments  causes  their  inversion,  intend- 
ing to  produce  a  cicatricial  nucleus  to  take  the  place  of  the  uterus 
between  the  bladder  and  the  rectum.  Bardenheuer  uses  an  exces- 
sively complicated  mode  of  drainage.  The  most  recent  is  formed 
by  a  triple  vaginal  tube.  The  middle  tube  is  not  perforated  and  is 
in  communication  with  four  branches  placed  in  the  peritonasal 
cavity.  One  of  the  branches  can  be  drawn  into  the  abdominal 
wound.  Martin  advises  inversion  of  the  order  that  I  have  indicated, 
first  removing  the  body  by  laparotomy,  then  the  cervix  through  the 
vagina.  He  has  made  this  operation  three  times,  has  had  two 
deaths,  and  the  patient  who  recovered  died  from  recurrence  in  the 
course  of  the  first  year. 

The  operation  for  total  extirpation  is  very  grave  as  to  mortality. 
The  statistics  of  Hegar  and  Kaltenbach  given  in  1881  comprised 
ninety-three  cases  with  sixty-three  deaths,  or  71  per  cent  mortahty. 
In  the  last  edition  of  their  work  (1886),  they  cai-ried  these  figures  to 
one  hundred  and  nineteen  operations  with  eighty  deaths,  67.2  per 
cent.  Besides  there  were  four  operations  not  terminated  and  one 
in  which  the  result  was  unknown.  These  five  cases  should  count 
among  the  deaths.  Recurrence  is  often  rapid,  and  nearly  always 
certain.  The  preceding  authors  know  of  only  one  case  of  pernia- 
nent  cure,  which  occurred  in  a  patient  operated  on  by  Freund  (1878). 


258  Displacements  of  the  Uterus. 

In  all  cases  where  patients  could  be  watched  recurrence  has  followed 
a  longer  or  shorter  interval.  Total  extirpation  through  the  abdomen 
is  then  an  operation  both  of  excessive  mortality  aud  of  doubtful 
benefit.  For  my  part  in  case  vaginal  hysterectomy  is  not  possible 
I  would  prefer  parasacral  hysterectomy. 

Finally,  when  the  limits  of  the  uterus  have  been  passed  by  the 
disease  Ave  are  confined  to  palliative  treatment,  curetting  followed 
by  cauterization.  Systematic  antisepsis  of  the  uterine  and  vaginal 
cavities  are  in  these  cases  of  great  importance.  The  products  of 
the  disintegration  of  the  neoplasm  cause  the  phenomena  of  putrid 
poisoning  if  allowed  to  remain  in  the  cavity.  I  have  seen  patients 
who  appeared  absolutely  septicemic  recover  after  curetting, 
antiseptic  tamponnement  aud  intrauterine  irrigations.  Sublimate 
solutions,  even  1-5000,  are  very  dangerous  in  this  class  of  cases  on 
account  of  the  large  absorbent  surface.  Only  water,  made  aseptic 
by  boiling  and  filtering,  should  be  used.  I  cannot  insist  too  much 
on  the  great  benefit  that  may  be  drawn  in  cases  of  acute  septicaemic 
poisoning,  from  the  introduction  of  strips  of  iodoform  gauze  into 
the  uterine  cavity,  leaving  them  twenty-four  to  forty-eight  hours. 
It  is  an  energetic  and  speedy  means  of  disinfection.  This  tam- 
ponnement of  the  uterus  has  been  recommended  by  Freund,  after 
curetting  for  cancer,  as  at  once  antiseptic  and  hiemostatic. 


CHAPTER  XVII. 


DISPLACEMENTS   OF    THE    UTERUS.  — GENERAL 

CONSIDERATIONS. ^ANTEVERSION.— 

ANTEFLEXION. 

The  uterus  is  firmly  fixed  posteriorily  by  the  utero-sacral  liga- 
ments, strong  and  unyielding,  the  fasciculi  of  which  are  attached 
to  the  cervix.  The  connections  with  the  bladder  in  front,  with  the 
broad  and  round  ligaments  on  the  sides,  serve  as  well  to  sustain  it 
as  to  keep  it  in  place,  so  to  speak,  and  to  maintain  it  in  the  position 
of  anteflexon  which  it  preserves  as  a  vestige  of  its  foetal  condition. 
The  normal  occlusion  of  the  vagina,  correcting  the  only  weak  point 
in  the  tonicity  of  the  pelvic  floor  leaves  it  to  oppose  the  action  of 
intra-abdominal  pressure  in  the  direction  of  gravity.  There  is 
equihbrium  over  all  its  surface,  and  the  uterus  floats  as  if  suspended 
in  the  midst  of  the  organs  of  the  pelvic  cavity  which  form  elastic 
cushions  for  it  on  aU  sides.     This  peculiar  condition  is  well  shown 


Displacements  of  the  Uterus. 


259 


Fig    129.— Position  of  the  uterus,  with  the  bladder  in  a  state 
of  medium  repletion  (Waldeyer). 

■when  the  uterus  is  artificially  drawn  down.  Just  the  moment  that 
the  utero-sacral  ligaments  are  stretched  and  resist  further  descent, 
the  uterus  yields  to  traction  with  the  gentle  resistance  of  a  body 
floating  on  water.     Repletion  of  the  bladder  carries  the  uterus 


260  Displace me7its  of  the  Uterus. 

higher  and  backward,  effac-iiig  momentarily  its  antetiexion  which 
reappears  and  is  exaggerated  when  the  bhidder  is  empty.  Eepletion 
of  the  rectal  ampulla  pushes  the  uterus  directly  in  front  and  higher, 
but  in  the  physiological  condition  it  is  rarely  carried  far  enough  to 
make  its  intiuence  notable.  The  action  of  the  bladder  is  more 
marked,  and  social  habits,  which  quickly  become  organic  habits, 
exaggerate  it  still  more.  In  short,  only  one  fixed  point  exists  for  the 
uterus,  the  attachment  of  the  posterior  ligaments.  As  this  occurs 
at  the  point  where  the  organ  is  thinnest  we  see  that  it  corresponds 
somewhat,  in  a  statical  i^oint  of  view,  to  a  pyramid  poised  on  its 
apex.  This  paradoxical  position  does  not  exist  m  animals.  It  is 
explained  by  the  attitude  of  the  human  species,  which  constitutes  an 
anomaly  in  the  animal  kingdom. 

If  we  consider  the  great  changes  in  the  size,  form  and  consistence 
of  the  uterus  at  each  pregnancy,  the  alterations  and  lesions  which 
parturition  may  inflict  on  the  neighboring  organs,  ligaments, 
muscles,  serous  membrane,  in  fact,  the  influence  which  efforts  of 
all  sorts  may  exert  on  an  equilibrium  thus  unstable,  we  are  sur- 
prised, not  that  the  displacements  of  the  uterus  are  so  frequent,  but 
that  they  are  not  more  so. 

I  shall  describe  first  those  displacements  which  are  produced  in 
the  vertical  plane,  for  which  the  name  deviations  has  been  reserved, 
including  flexions  and  versions ;  those  which  are  produced  in  the 
horizontal  plane,  elevation,  prolapsus,  inversion,  will  be  studied 
later. 

Division. — Displacements  in  the  vertical  plane  are  commonly 
divided  into  versions  and  flexions,  according  as  the  organ  is  totally 
deviated  or  whether  the  body  alone  is  deviated  and,  in  consequence, 
flexed  on  itself.  There  are,  ante  and  retro  version,  ante  and  retro 
flexion,  latero-version  and  latero-flexion.  These  last  very  rarely 
occur  alone,  but  are  often  complicated  with  the  preceding.  I  shall 
confine  myself  to  this  simple  mention  of  them.  ^^Tien  the  whole 
uterus  is  displaced  forward  or  backward,  it  is  said  to  be  ante  or 
retro  posed  ;  these  words  having  only  a  descriptive  value,  nosologi- 
cally  none. 

Historical  sketch .^The  history  of  uterine  deviations  has  passed 
through  many  successive  phases.  Unrecognized  before  Eecamier,  at  a 
period  when  the  i^rincipal  role  of  uterine  diseases  ^\■ithout  neoplasms 
was  attributed  to  prolapsus,  consigned  to  the  second  rank  by  Eeca- 
mier and  Lisfranc  by  the  preponderant  place  given  to  ulcerations ; 
versions  and  flexions  took,  on  the  contrary,  with  Velpeau,  the  first 
place  in  uterine  pathology.  Their  role  was  then  considerably 
exaggerated,  until  the  time  when  Gosselin  created  a  reaction  in 
favor  of  metritis.  At  present  gynsecologj-,  becoming  more  analytic 
and  consequently  more  eclectic,  tends  to  give  to  each  of  these 
morbid  states  the  place  due  to  it.     It  brings  forward,  moreover, 


Displacements  of  the  Uterus.  261 

new  or  previously  ignored  elements,  those  resulting  from  the  patho- 
logical state  of  the  appendages.  It  is  now  known  that  deviation  of 
the  uterus  does  not  of  itself  constitute  a  disease,  but  is  only  a  factor, 
or,  to  be  more  precise,  a  coefficient  of  a  complex  morbid  condition 
in  which  the  displacement  enters  only  as  an  important  component 
part.  There  is  no  gynaecologist  who  has  not  had  occasion  to  ob- 
serve marked  displacements  in  women  who  present,  hoAvever,'no 
other  bad  symptom.  Some  authors,  taking  this  incontestable  fact 
as  a  basis,  have  not  hesitated  to  deny  totally  the  pathogenetic  role 
of  displacements.  This  is  to  fall  into  the  other  extreme.  If  the  dis- 
placement is  not  a  disease  in  itself,  it  creates  for  the  displaced 
organs  a  special  vulnerability  resulting  from  circulatory  difficulties, 
by  increase  of  venous  tension  and  by  nutritive  changes,  wluch  may 
be  the  consequence.  It  favors  and  keeps  up  inflammation  in  the 
cavity  and  on  the  surface  of  the  uterus. 

Moreover,  prolapsus  of  the  appendages,  which  often  participate 
in  inflammation  of  the  uterus,  may  be  the  soiirce  of  nervous  reflex 
troubles,  the  influence  of  which  cannot  be  neglected,  especially  in 
posterior  displacements.  Finally,  adhesions  due  to  perisalpingitis, 
if  they  occur  then,  by  fixing  the  uterus  in  a  vicious  position,  bring 
on  the  most  painful  phenomena,  as  a  consequence.  We  see  then 
that  the  idea  of  uterine  displacement,  formerly  simple  and  having 
only  an  anatomo-pathological  importance,  includes  for  us  to-day, 
under  the  same  clinical  designation,  complex  elements  whose 
treatment  should  be  taken  into  consideration  as  much  and  some 
times  more  than  the  changes  in  the  axis  of  the  organ,  namely,  me- 
tritis, prolapsus  of  the  healthy  or  inflamed  appendages,  peri- 
salpingitis ;  finally,  in  a  great  measure,  especially  at  the  beginning, 
excess  of  uterine  mobility  due  to  lax  condition  of  the  ligaments. 

I.  —  Anteversion.  —  Pathological  anatomy.  —  ^Jitiology.  —  The 
normal  curvature  of  the  uterus  coincides  nearly  with  the  curved  axis 
of  the  pelvis.  In  anteversion  this  curvature  is  effaced  and  the  organ 
falls  forward,  lying  behind  the  pubes,  on  the  bladder :  the  cervix 
is  directed  backwards  (Fig.  130).  The  uterus  is  then  generally  in- 
creased in  size  by  a  certain  degree  of  metritis.  There  then  often 
exists  a  perimetritic  exudation,  toward  one  of  the  poles  of  the 
organ,  either  in  froiit  of  the  fundus  or  backward  toward  the 
cervix,  which  fixes  the  uterus  in  its  malposition.  The  great  cause 
of  anteversion  lies  in  the  changes  of  structure  of  the  uterus  after 
confinement  or  abortion  and  in  a  vicious  involution,  brought  on  by 
a  slight  infection;  the  organ  takes  this  position  when  it  is  still 
softened  and  preserves  it  because  its  normal  tonicity  has  not 
returned ;  peritonaeal  adhesions  finally  occur  and  fix  it  thus.  The 
weight  of  a  tumor  may  also  cause  this  displacement,  which  is  then 
only  an  epiphenomenon. 

Symptoms. — The  uterine  syndrome  which  I  described  in  connection 


262  Displacements  of  the  Uterus. 

■with  metritis,  may  be  fouud  here  with  all  its  characters.  Especially 
must  be  noted  the  rectal  and  vesical  tenesmus,  exaggerated  by  the 
pressiire  of  the  fundus  and  eer\'ix  of  the  uterus,  but  which  are  often 
missing  and  occur  in  simple  metritis.  Difficulty  in  walking,  nervous 
reflex  phenomena,  are  common  to  all  displacements  and  attribu- 
table, no  doubt,  to  uterine  mobility  and  to  the  enteroptose,  which 
results,  more  than  to  the  displacement  of  the  uterus ;  this  Droves 
the  efficacy  of  immobilization  by  the  pessary  or  belt. 


Fig.  130. — Anteversion. 

Diagnosis. — Bimanual  palpation  permits  easy  diagnosis;  the 
vaginal  finger  should  seek  the  cervical  orifice  veiy  far  back,  against 
the  posterior  cul-de-sac,  then  coming  forward  the  body  is  felt  across 
the  anterior  cul-de-sac  and  may  be  followed  along  its  anterior  face, 
while  tlie  hand  placed  on  the  pubes  explores  its  anterior  face  lying 
horizontally.  The  use  of  the  sound  is  difficult  and  is  not  generally 
necessary.  It  is  employed  only  when  doubts  are  felt  as  to  the 
nature  of  tlie  tumor  found  in  the  anterior  cul-de-sac,  and  if  there 
is  a  question  between  the  fundus  of  the  uterus  or  a  superadded 
tumor,  fibroid,  inflammatory  or  bloody  exudation.  Anteflexion  will 
be  recognized  by  the  sulcus  existing  at  the  point  of  the  union  of 
the  cervix  and  body.  To  facilitate  the  entrance  of  the  sound  into 
the  cervix,  the  anterior  lip  may  be  seized  ^vith  a  volsella  and  the 
organ  drawn  down  very  shghtly.  Eectal  touch  will  also  afford 
useful  information  in  such  cases,  showing  whether  the  uterus  is  in 
normal  situation  or  not. 

Treatment. — Metritis  is  what  causes  and  maintains  anteversion 
and  is  what  should  receive  the  first  attention.  It  is  necessaiy  to 
be  sure  that  acute  inflammation  outside  the  uterus  or  in  the  tubes 
does  not  exist,  before  instituting  energetic  treatment  of  the  uterine 
mucosa.  We  should  commence  treatment  with  appropriate 
measures,  among  wliich  are  placed  in  the  first  rank  very  hot  vaginal 


Displacements  of  the  Uterus.  263 

douches,  glycerine  tampons,  frequent  sitz -baths  and  repeated 
blistering  on  the  lower  part  of  the  abdomen.  When  all  acute  symp- 
toms have  disappeared,  curetting  is  performed  and  followed  with 
an  in]ection  of  percliloride  of  iron,  according  the  rules  that  have  been 
previously  given.  Eeduction  need  not  be  practiced,  the  position 
of  the  organ  being  a  simple  exaggeration  of  the  normal  condition. 
If,  after  the  metritis  is  cured,  pains  persist,  they  can  be  due  only 
to  reflexes  taking  thek  origin  from  ligamentous  laxity  and  enter- 
optose.  Then  care  should  be  taken  to  immobilize  the  organ  and 
keep  it  in  place.  For  that,  perform  either  of  two  methods :  the 
abdominal  or  the  vaginal. 


The  best  belt  for  these  forward  displacements  is  the  hypogastric 
belt  with  a  moveable  pad,  which  is  inclined  either  by  the  action  of 
elastic  straps,  or  the  use  of  a  screw  which  is  fastened  after  it  is 
apphed  below  the  pubes.  The  best  anteversion  pessary  is  one  of 
the  class  which  I  call  indifferent  pessaries,  that  is  to  say,  they  can 
be  applied  indifferently  to  aU  cases,  because  their  modus  operandi 
is  to  distend  the  vaginal  culs-de-sac  and,  in  consequence,  to 
immobilize  the  uterus  by  steadying  the  cervix.  Mayer's  pessary, 
consisting  of  a  ring  of  elastic  rubber,  is  the  indifferent  pessary  j?«r 
excellence ;  it  is  easily  applied,  removed  and  cleaned.  Forceps  are 
constructed  which  permit  its  introduction  into  the  vagina  without 
pain.  With  experience  the  same  end  may  be  accomphshed  by 
bending  it  between  the  thumb  on  one  side  and  the  index  and  middle 
fingers  on  the  other.  It  is  easier  to  place  when  the  woman  is  in  the 
lateral  or  genu-pectoral  position.  The  upper  part  of  the  pessary 
has  only  to  be  placed  in  the  posterior  cul-de-sac  and  then  its  superior 
part  is  left  to  spring  back  a  little  and  it  places  itself  automatically. 
Its  dimensions  are  chosen  according  to  those  of  the  vagina.  A 
pessary  which  does  not  give  the  patient  pain  may,  Avithout  incon- 
venience, be  left  in  place  two  or  thi-ee  months,  it  prevents  neither 
coitus  nor  fecundation.     At  the  end  of  this  time,  it  is  removed  for 


264 


JJispliKemenU  of  tli^  Uterus. 


cleansing  in  carbolized  water  and  the  patient  is  advised  to  go  with- 
out it  for  some  days  and  not  to  have  it  restored  unless  its  employ- 
ment is  still  found  useful.  Many  special  pessaries  have  been 
invented  and  praised  for  anteversion.  I  confess  I  have  never 
derived  the  least  advantage  fi-om  them.  1  have  presented  illus- 
trations sho\\ing  the  application  of  Hewitt's  cradle  pessary.  The 
use  of  Thomas'  pessary  -will  be  better  imderstood  when  referring, 
further  on,  to  the  use  of  Hodge's  pessaiy  in  retroflexion ;  in  fact, 
this  pessary  is  applied  like  Hodge's,  fi-om  which  it  only  differs  by 
a  movable  piece  like  a  horse  shoe,  which  passes  in  front  of  the  cervix 
to  sustain  the  body  of  the  uterus.  Galabin's  pessary  presents  a 
strong  anterior  thickening,  intended  for  the  same  purpose 

For  treatment  of  the  auiemia  and  nervous  irritability,  hydro- 
therapy and  preparations  of  non  and  quinine,  are  especially  useful. 
II.    Anteflexion. — Pathological  anatomy. — ^Etiology. — Ante- 
flexion is  the  exaggeration  of  the  normal 
condition   of   anteflexious.     Before  this 
was  well  known,  the  normal  attitude  of 
the  organ  was  often  taken  for  a  patho- 
logical deviation   of   the  uterus.     It   is 
difficult  to  trace  an  exact  Unlit  between 
the  physiological  and  the  morbid  states ; 
the  morbid  state,  however,  may  be  said 
to   commence   when    the   angle   of  the 
flexion   is  perceptible  to  the  exploring 
finger    as    an    abmpt   angle.     Gaillard 
Thomas  names  thi-ee  varieties :     1.  Cor- 
poral flexion ;  the  body  is  flexed  on  the 
cervix  not  normally  situated — this  is  the 
ordinary  type.,   2.  Cei-vical  flexion,  the 
reverse  of  the  first.     3.  Cervico-corporal  flexion,  when  the  two  seg- 
ments of  the  uterus  are  flexed  one  on  the  other. 


e.  TIC  Ml  ANN -00. 


Fig.  132. — Hewitt's  pessary. 


6  JIEM  ANN-CO 


fi.TlEMfeNH-CO. 
Fig.  133. — Thomas'  anteversion  pessary. 


In  the  etiological  point  of  view,  two  kinds  of  anteflexion  exist : 
congenital  and  acquired.  In  early  infancy,  as  ^^"ith  the  foetus,  there 
is  an  exaggerated  curvature  of  the  organ,  the  body  of  which  is  still 


Displacements  of  the  Uterus. 


265 


small  compared  with  the  already  well-developed  cervix.  It  suffices, 
at  the  time  of  puberty,  that  the  growth  of  the  uterus  be  irregular, 
the  anterior  wall  being  of  slower  development  than  the  posterior 
wall,  for  so-called  congenital  anteflexion  to  become  manifest ;  it 
may,  as  a  second  mark  of  arrested  development,  coincide  with  an 
infantile  cervix  which  will  be  relatively  long  and  conical  (Fig.  135). 


Fig.  l34.^Anteflexion  of  infantile  origin.     (Curvature  at  an  acute  angle; 
globular  body.) 


Fig.  135. — Very  acute  anteflexion  with  subvaginal  hypertrophy  of  the  cervix. 

At  other  times  also  the  atrophy  of  the  anterior  Hp  wiU  be  very 
manifest,  and  furnishes  a  sure  indication  of  the  atrophy  of  the  cor- 
responding waU ;  finally  this  anteflexion  has  been  seen  to  coincide 
with  hyperplasia  of  all  the  genital  organs.  Congenital  anteflexions 
do  not  present  as  acute  an  angle  as  the  acquired  condition. 


266 


Displacements  of  the  Uterus. 


Fig.  136.; — Anteflexion  from  shortening  of  the  utero-sacral  ligaments. 


Fig.  137.- 


-Anteflexion  combined  with  retroposition.     Adhesions 
in  Douglas'  cul-de-sac. 


Anteflesions  may  be  acquired  at  puberty,  if,  when  the  uterus 
swells  and  softens  under  the  influence  of  the  fii'st  period,  the  young 
girl  is  exposed  to  bad  hygienic  influences ;  excessive  fatigue  from 
riding,  masturbation  and  all  causes  of  virginal  metritis  may  here 
develop  both  inflammation  and  displacement.  We  can  well  under- 
stand how  a  general  softening  of  the  organ  permits  it  to  fold  at  the 
isthmus,  as  on  a  Mnge,  and  bend  to  the  side  to  which  its  infantile 
cm-vatui-e  has  already  inclined  it.  Sometimes  the  effects  of  a  fall 
have  been  the  origin  of  these  accidents.  Puerperal  metritis  should 
be  counted  among  the  causes  of  acquired  anteflexions,  although 
it  much  more  frequently  produces  retroflexion.  We  may  \vith 
reason  attribute  it,  as  E.  Maiiiu  does,  to  the  absence  of  sufficient 


Displacements  of  the  Uterus.  267 

involution  of  the  posterior  wall  of  the  uterus  after  confinement  or 
abortion ;  this  last  would  be  caused  by  the  debris  of  the  membranes 
or  placenta  causing  a  more  intense  local  inflammation  at  the  point 
of  their  implantation.  Schultze,  according  to  Martin,  attaches 
great  importance  to  posterior  perimetritis,  situated  at  the  edge  of 
the  utero-sacral  ligaments  and  causing  their  retraction  (Fig.  13ft). 
Schultze  affirms  that  in  such  cases  the  cervix  is  always  situated 
higher  in  the  pelvic  cavity  and,  in  consequence,  the  vagina  is 
elongated,  while  the  origin  of  posterior  perimetritis  he  attributes 
most  frequently  to  puerperal  or  gonorrhoeal  infection.  I  believe  it  is 
more  fi-equently  due  to  perisalpingitis.  The  adhesions  wMeh  result 
from  it,  and  which  fix  the  cer^ax  firmly  posteriorly,  may  then  push 
forward  and  cause  flexion  of  the  body  at  the  level  of  the  isthmus, 
weakened  by  the  attending  metritis,  while  the  cervix,  hypertrophied 
and  sclerosed  by  an  old  inflammation,  remains  rigid  (Fig.  137). 
Sub  vaginal  elongation  of  the  cervix,  resulting  from  inveterate 
catarrh,  very  often  coexists  with  anteflexion. 

Symptoms. — Congenital  anteflexion  causes  amenorrhcea,  or  a  late 
appearance  of  the  menses,  when  it  coincides  with  an  infantile  con- 
dition of  the  internal  genital  organs.  If  the  menses  appear  at  the 
usual  period,  they  are  scanty  and  irregular.  At  other  times,  the 
flow  being  normal  in  quantity,  the  phenomena  of  dysmenorrhoea 
appear.  Violent  pains  in  the  back  occur  while  the  blood  distends 
the  cavity  of  the  uterus  above  the  point  of  flexion ;  then,  at  a  certain 
time,  the  obstacle  is  overcome,  the  blood  is  suddenly  expelled  in  a 
flood,  more  or  less  mixed  with  clots,  and  sometimes  with  a  very 
strong  odor  which  is  attributable  to  its  long  stagnation.  This 
mechanical  theory  of  the  pains  of  uterine  dysmenorrhoea  depending 
on  anteflexion  has  been  widely  adopted  since  the  time  of  J.  Y. 
Simpson  and  Marion  Sims.  It  is  not  accepted  by  Fritsch,  who 
explains  the  pains  by  irritation  of  the  nerves  due  to  congestion,  to 
abnormal  vascular  tension  which  is  produced  by  the  curvature  of 
the  vessels  at  the  edge  of  the  flexion.  It  is,  however,  difficult  not  to 
attribute  very  great  importance  to  the  obstacle,  when  we  note  the 
paroxysmal  character  of  the  crisis  and  of  the  flow.  It  may  even  be 
asked  if  the  posterior  perimetritis  noted  by  Schultze  is  not  some- 
times the  result  rather  than  the  caiise  of  anteflexion,  which  every 
month  causes  the  eifusion  of  some  drops  of  blood  into  Douglas'  cul- 
de-sac,  tln-ough  the  tubes,  producing  thus  a  kind  of  minute  and 
periodical  htematocele.  Thus  the  acute  and  febrile  symptoms, 
which  sometimes  terminate  the  crisis  of  dysmenorrhcea,  are 
explained.  The  patients  present  all  the  symptoms  pertaining  to 
the  uterine  syndrome.  The  dysuria  is  generally  very  marked. 
Nervous  reflex  accidents  very  prominent.  Pains  during  conjugal 
relations,  or  dysspareunia  (Barnes),  are  frequently  noted.  Sterility 
is  the  rule  and  if  conception  takes  place  abortion  is  to  be  feared. 


268  Displacements  of  the  Uterus. 

Dia())iosis.—lt  the  most  frequent  type  is  acquired,  anteflexions 
or  corporal  anteflexion  is  in  question,  the  finger  in  the  anterior  cul- 
de-sac  of  the  vagina  will  feel  the  fundus  of  the  uterus  tilted  forward 
almost  on  the  same  plane  as  the  cei-vis.  In  di-awing  down  the  organ 
by  bimanual  palpation  the  uterus  is  made  accessible  to  the  index 
finger  and  it  will  feel  the  angle  of  the  flexion.  The  cervix  is  in  the 
axis. 

In  the  cervical  variety  of  anteflexion,  the  cervix  is,  on  the  con- 
trary, oblique  from  above  do%^"nward,  and  from  before  backward ; 
the  orifice  looking  dh-ectly  up  in  front.  Belying  on  the  feel  of  the 
cervix  alone,  it  would  be  thought  to  be  retroversion ;  but  bimanual 
palpation  reveals  the  body  in  its  natural  place. 


Fig.  138. — Anteflexion  simulated  by  a  fibroid  of  the  anterior  wall  of  the  uterus. 

In  the  variety  of  the  cervico-eorporal  anteflexion,  the  direction 
of  the  cervix  is  the  same  as  in  the  preceding,  but  the  body  is  also 
curved  to  the  front  and  hidden  behind  the  pubes.  By  depressing 
the  anterior  cul-de-sac  of  the  vagina  in  front  of  the  cervix,  it  is  felt. 
Sometimes  the  uterus  is  thus  so  much  rolled  on  itself  that  the  angle 
of  the  flexion  cannot  be  felt,  and  it  forms  a  sort  of  globular  mass 
which  may  easily  be  mistaken  for  a  fibroid  or  an  inflammatory 
induration.  The  opposite  error  may  also  be  committed  (Fig.  138). 
The  sound  will  then  be  very  useful.  The  introduction  of  the  sound 
is  facilitated  by  seizing  the  cervix  with  the  volseUa  and  di-awing  it 
a  little  backward  and  downward ;  the  sound  should  be  cui'ved  to 
siut  and  carried  with  great  care  in  the  supposed  dii-ection  of  the 
uterine  cavity,  while  one  finger  presses  on  the  anterior  cul-de-sac 
to  straighten  the  organ  a  httle.  When  the  sound  has  entered  the 
uterine  cavity  it  is  suificient  to  carry  the  handle  toward  the  front. 
Then  by  bimanual  palpation,  associated  with  rectal  touch,  the  two 
surfaces  of  the  uterus  may  be  explored  and  the  presence  or  absence 


Displacements  of  the  Uterus.  269 

of  a  superadded  tumor  be  determined,  and  the  mobility  of  the 
uterus  be  noted.  Tins  exploration,  however,  should  be  attempted 
only  when  the  recent  appearance  of  the  menses  has  removed  all 
doubt  with  regard  to  existing  pregnancy. 

A  calculus  of  the  bladder,  depressing  the  anterior  vaginal  cul-de- 
sac,  will  not  be  taken  for  anteflexion  except  when  the  methodical 
examination  of  the  uterus  and  catheterism  of  the  bladder  afe 
neglected. 

Treatment. — Acquired  anteflexion  does  not  generally  cause  suf- 
fering except  by  the  added  inflammation  or  by  pressure  on  the 
bladder  and  excess  of  uterine  mobihty ;  help  may  be  had  from  a 
belt  or  pessary,  unless  previous  reduction  is  necessary.  But  it  is 
especially  the  concomitant  metritis  which  requires  treatment.  In 
the  simpler  class  of  cases  curetting,  followed  by  injections  of  iodine, 
will  be  sufficient.  Sometimes  it  is.necessary  to  have  recourse,  either 
to  biconical  amputation,  or  to  excision  of  the  mucous  membrane . 
according  to  Sclu'oeder's  method.  Thus  is  caused  a  rapid  progres- 
sive involution  of  the  cervical  hypertrophy,  that  will  very  much 
surpass  the  immediate  result  given  by  the  bistoury  and  which,  with 
the  amelioration  of  the  metritis,  will  cause  the  disappearance  of 
the  morbid  symptoms  that  might  be  attributed  to  the  displacement. 
This  mil,  however,  correct  itself  little  by  little.  It  seems  probable 
to  me  that  some  of  the  good  results  obtained  by  Sims,  with  his 
sagittal  discision  of  the  cervix,  wliich  once  had  so  great  repute, 
and  which  was  so  much  abused,  should  be  attributed  to  the  indnect 
effect  of  the  operation  on  the  involution  of  the  uterus  affected  with 
chi'onic  metritis,  rather  than  to  the  restoration  of  the  calibre  of  the 
cervix. 

Congenital  anteflexion  claims  interference  either  on  account  of 
the  very  painful  dysmenorrhcea  it  causes  or  to  remedy  the  sterility. 
Straightening  and  dilatation  have  been  praised.  If  they  are  de- 
termined on,  it  is  well  to  combine  them  and  to  precede  all  attempts 
at  reduction  by  the  introduction  of  laminaria  tents  after  having 
learned  by  the  sound  the  size  and  direction  of  the  cervico-uterine 
canal.  Sufficiently  thin  laminaria  tents,  prepared  with  iodoform, 
are  flexible  and  may  be  curved  to  suit.  It  is  useless  to  seek  gteat 
dilatation.  The  principal  use  of  the  tents  is  to  soften  the  tissues 
to  facilitate  manipulation  in  view  of  their  subsequent  reduction. 
This  is,  however,  commenced  by  dilatation  itself.  After  having 
enlarged,  dilated  and  rectified  the  axis  partially  by  the  application 
of  one  or  two  dilating  tents,  Hegar's  bougies  should  be  passed  two 
or  three  times  a  week,  fixing  the  cervix  Avith  the  volsella  and  by 
pressing  back  the  uterus  with  the  finger  in  the  anterior  cul-de-sac. 
Bougies  No.  10  or  12  will  be  large  enough.  Rapid  reduction,  by 
giving  the  sound  a  turn  which  carries  the  body  suddenly  backward, 
is  quite  out  of  place  here. 


•270  Displacements  of  the  Uterus. 

As  iu  these  eases  the  uteiais  is  almost  always  imperfectly  de- 
veloped, oue  of  the  principal  benefits  of  the  treatment  may  be  the 
increased  nutritive  activity  caused  by  the  progressive  dilatation  and 
the  systematic  passage  of  sound. 

Besides  the  pessaries  I  have  already  uidicated  and  which  all 
apply  indifferently  to  anteversion  or  anteflection,  there  is  a  kind 
described  especially  for  anteflexion.  That  of  Faucomi-Bames  is 
a  combination  of  Hodge's  and  Graily  Hewitt's.  Thomas  has  invented 
a  complicated  instrument  consisting  of  a  Hodge's  pessary  support- 
ing a  cup  on  an  intrauterine  stem  ;  I  may  also  mention  Gelu-ung's 
pessary.  I  much  prefer  hypogastric  belts  to  vaginal  pessaries  in 
cases  of  anteflexion  as  well  as  in  anteversion. 

Stem  pessaries,  or  intrauterine  pessaries,  so  extolled  Ijy  Simpson 
in  England  and  Yalleix  in  France,  and  wliich  have  caused  so  many 
accidents  when  used  without  antiseptic  care,  should  be  rarely 
used.  But  iu  case  of  timid  or  nervous  women,  for  whom  gradual 
dilatation  is  too  tedious  or  iu  intractable  cases,  a  dilator  may  be 
left  in  situ.  The  old  stem  pessaries  were  all  rectiUnear,  which  is 
a  mistake,  as  the  normal  state  of  the  uterus  is  one  of  anteflexion. 
They  are  generally  made  of  two  metals,-  copper  and  zinc,  whose 
galvanic  action,  joined  to  dilatation,  were  considered  to  have  a  salu- 
tary influence.  Fehling  has  constructed  a  much  more  rational 
instrument ;  it  is  a  tube  of  thick  glass,  with  openings,  provided  with 
a  pavilion  and  slightly  cmwed ;  it  can,  however,  be  easily  cmwed 
in  the  flame  of  a  lamp.  It  is  filled  with  iodoform  powder  maintained 
by  a  cotton  ball,  and  it  is  introduced  into  the  uterus,  care  being 
taken  that  it  is  about  one-haK  a  centimetre  shorter  than  the  cavity 
of  the  organ.  The  patient  is  kept  in  bed  eight  days  for  obseiwation ; 
after  that  she  may  be  permitted  to  get  up,  and  it  should  not,  accord- 
ing to  this  author,  be  removed  before  eight  or  ten  months.  The 
instrament  is  retained  by  the  projection  of  the  mucous  membrane 
into  its  opening.  It  is  veiw  Hght  and  has  no  tendency  to  fall  out.  I 
think,  however,  that  eight  months  is  too  long  a  time,  and  the  useful 
effect  ought  to  be  produced  at  the  end  of  oue  or  two  months  at  the 
most. 

For  the  severe  pains  of  dysmenorrhea  sedative  suppositories  of 
morphine  and  belladonna  may  be  employed,  two  or  thi-ee  in 
twenty-foul"  hours  being  introduced  into  the  rectum  as  needed. 
Finally,  if  persuaded  that  the  dysmenorrhcea  is  of  ovarian  and  not 
uterine  origin,  so  that  the  anteflexion  plays  only  an  apparent  parf, 
this  epipheuomenon  should  not  cause  delay.  If  the  intensity  of 
the  symptoms  is  suflicieut  to  justify  it,  castration  or  Battey's  oper- 
ation should  be  resorted  to. 

Confjcnital  antetie.rioiis. — The  cervix  is  often  conical,  with  stenosis 
of  the  OS.  This  is  the  principal  cause  of  pain.  For  these  cases 
bilateral  incision  has  long  been  practiced  with  the  bistomy,  Simp- 


Posterior  Displacements.  271 

son's  metrotome,  Collin's  hysterotome  or  Kuchemeister's  scissors. 
The  results  thus  obtained  are  not  permanent,  for  the  cicatrization 
almost  surely  re-estabHshes  the  original  condition.  A  true  stoma- 
toplastic  operation,  by  amputation  of  biconical  section,  is  decidedly 
preferable. 

Cervical  anteflexion  presents  special  indications ;  it  is  especially 
to  combat  sterility  that  operations  of  dicision  are  practiced.  Marion 
Sims  incises  the  posterior  lip  with  his  short-bladed  bistoury. 
Emmet  performs  the  same  incision  with  his  curved  scissors.  He 
accomplishes  the  comieetion  of  the  canal  by  incising  with  a  curved 
tenotome  a  certain  thickness  of  tissue  on  the  anterior  surface.  The 
incision  is  kept  open  by  a  glass  tube.  A  triangular  fi-agment  has 
also  been  removed  from  the  posterior  lip,  or  this  lip  has  been 
entirely  removed.  More  complicated  plastic  operations  have  been 
proposed  (Kustner) ;  I  think  they  are  all  to  be  condemned  aHke. 
If  some  deformity  of  the  cervix  exists,  the  best  way  is  to  amputate 
it  (according  to  the  rules  given  in  the  chapter  on  metritis)  taking 
special  care  to  provide  for  an  ample  orifice. 


CHAPTER  XVIII. 


POSTERIOE,   DISPLACEMENTS. 

Posterior  displacements  are  much  the  most  frequent,  and  occupy  a 
prominent  place  in  uterine  pathology.  Sanger,  out  of  seven  hundred 
diseases  of  women,  has  counted  one  hundred  and  eight  cases  of 
retrodeviations,  being  15.14  per  100.  Winckel  has  found  19.10  and 
Lohleui  17  to  18  per  100. 

Retroversion. — Pathological,  anatomy. — JiJtiology. — The.tonicity 
of  the  broad  hgaments,  the  round  and  the  utero-sacral  ligaments, 
which  it  must  be  remembered  contain  a  great  quantity  of  unstriated 
muscularfiber,  ordinarily  hold  the  organ  in  its  normal  posture.  But 
if  its  weight  is  augmented  by  inflammation  and  especially  by  tardy 
post-partum  involution,  the  ligaments  themselves  undergo  relax- 
ation while  the  uterus  is  swollen  by  metritis.  Eetroversion  may 
then  become  permanent  from  the  influence  of  prolonged  hori- 
zontal decubitus.  Adhesions  then  fix  the  organ  in  its  new  position. 
This  posterior  pelvic  peritonitis,  taking  its  origin  at  the  level  of  the 
pavilion  of  the  inflamed  tubes  is,  perhaps,  sometimes  the  primary 
cause. 

A  sudden  effort,  a  fall,  is  at  other  times  the  determining  cause  of 


272  Postericy)-  Displacements, 

the  displacement ;  prolapsus  of  the  vagiua  and  slight  prolapsus  of 
the  uterus  may  also  occur,  lietroversion  is  less  common  than 
retroflexion. 


Fig.  139. — Retroversion,  with  extensive  adliesions  of  the  posterior  surface. 


Fig.  140. — Retroversion  consecutive  to  a  subinvolution  of  the  anterior  wall  in  which 
the  insertion  of  the  placenta  can  still  be  distinguished  (E.  Martin). 

Symptoms. — When  the  displacement  is  abruptly  produced  by 
violent  exertion  it  is  accompanied  with  sudden  pain  and  various 
nervous  phenomena,  as  in  a  sudden  j)rolapsus  under  the  same 


Posterior  Displacements. 


273 


conditions.  When  the  displacement  is  gradually  developed,  the 
symp-toms  are  generally  confounded  with  those  of  metritis  or  the 
circumscribed  parametritis  to  wliich  it  gives  rise ;  the  uterine  syn- 
drome is  observed.  Sterility  is  the  rule.  As  to  vesical  and  rectal 
tenesmus,  they  may  be  very  marked  ;  sometimes  they  are  absent. 
Palpation,  aided  by  touch,  reveals  the  position  of  the  cervix  in  front', 
that  of  the  uterus  behind,  toward  the  concavity  of  the  sacrum, 
where  it  is  more  or  less  immovable.  The  two  segments  of  the 
uterus  lie,  however,  in  a  direct  line. 

Diagnosis. — Bimanual  palpation,  aided  by  rectal  touch,  and,  if 
necessary,  the  use  of  the  sound,  are  the  means  used  for  determming 
the  position  of  the  organ,  the  cervix  being  dii-ected  toward  the  front 
while  the  fundus  may  be  felt  through  the  posterior  cul-de-sac. 
What  distinguishes  this  deviation  from  retroflexion  is  the  absence 
of  an  angle  between  the  body  and  the  cervix.  We  must  not  confound 
it  with  a  fibroid  of  the  posterior  wall  of  the  uterus,  a  retro-uterine 
haematocle,  an  ovarian  tumor  or  tumor  of  the  Fallopian  tube,  in 
Douglas'  cul-de-sac,  an  inflammatory  nucleus  from  posterior  para- 
metritis, or  accumulated  scybalse.  They  may  all  be  differentiated 
by  the  use  of  the  uterine  sound  combined  with  other  modes  of  explo- 
ration ;  it  will  be  especially  useful  to  differentiate  cervico-corporal 
anteflexion  which,  from  its  antero-posterior  direction,  is  the  source 
of  almost  inevitable  error  if  we  confine  ourselves  simply  to  explo- 
ration of  the  cervix.  The  treatment  is  the  same  as  that  for  retro- 
flexion. 

Retroflexion. — Pathological  anatomy. — Etiology.  —  Contrary  to 
what  is  true  of  anteflexion,  retroflexion  rarely  dates  from  infancy 
or  fi-om  puberty.  However,  it  may 
succeed  to  vaginal  metritis  and  ha- 
bitual constipation.  Masturbation 
favors  its  development  (Fritsch). 
In  the  great  majority  of  cases  retro- 
flexion succeeds  to  puerperal  me- 
tritis ;  the  absence  of  involution  of 
the  anterior  wall  of  the  uterus, 
caused  by  the  insertion  of  placental 
debris,  plays  here,  according  to  E. 
Martin,  a  role  analogous  to  that 
which  I  have  indicated  for  ante- 
flex-ion.  A  considerable  influence 
must  also  be  attributed  to  the 
weight  of  the  inflamed  organ,  and  to  the  relaxation  of  the  broad  and 
round  ligaments  which  fafl.  to  keep  the  organ  in  place  anteriorly. 
While  the  cervix  remains  fixed  by  the  more  resisting  utero-sacral 
ligaments,  the  flaccidity  of  these  ligaments  allows  the  body  of  the 
uterus  to  curve  back  at  the  isthmus,  m  obedience  to  the  laws  of 


Fig.  141. 


-Extreme  retroflexion  of 
the  uterus. 


274 


Toster'ior  T)isplarements. 


gravity  and  the  pressi;re  of  the  intestines.  Finally,  retroflexion  may 
result  from  simple  retroversion  or  even  auteversion ;  it  is  especially 
possible  to  the  latter  class  of  cases  when  the  seat  of  flexion  is  flexible, 
like  a  hinge.  The  cervix  is  directed  do^\■nward  and  toward  the  front ; 
it  is  ordinarily  near  the  ^iilva,  for  there  is  often  a  little  prolapsus. 
The  external  os  is  half  open,  the  lips  swollen  owing  to  the  obstructed 
venous  circulation  resulting  from  the  flexion  of  the  vessels;  we 
must  not  forget,  however,  that  it  occurs  almost  always  in  women 
affected  at  the  same  time  with  a  metritis  of  puerperal  origin.  The 
body  of  the  organ  occupies  Douglas'  cirl-de-sac.  A  marked  thinness 
has  been  found  on  either  of  the  walls,  the  anterior  (Euge)  or  the 
posterior  (Fritsch). 


Fig.  142. — Retroflexion  of  the  uterus  in  a  nulliparous  woman. 

Adhesions  are  often  found,  some  perimetritic,  produced  by  exu- 
dations into  Douglas'  cul-de-sac,  others  parametritic,  situated  under 
the  serosa  at  the  utero-sacral  ligaments.  Schultze  attributes  to 
relaxation  and  loss  of  tonicity  of  these  ligaments  (Douglas'  folds) 
under  the  influence  of  posterior  post-pai-tum  parametritis  an 
important  role  in  the  production  of  all  uterine  displacements.  To 
clearly  understand,  then,  the  production  of  retroflexion,  it  is  neces- 
sary to  suppose  that  in  the  first  phase  of  acute  inflammation,  these 
ligaments  retain  all  their  resistance,  so  as  to  still  fix  the  cervix ;  it 
would  only  be  later,  dm-ing  the  disappearance  of  the  exudate,  that 
nutrition  of  the  ligaments  impaired  causes  their  flaccidity.  Accord- 
ing as  the  isthmus  has  resisted  or  yielded  in  the  fii'st  phase,  we 
have  a  retroversion  or  retroflexion.  In  other  words,  version  supposes 
an  alteration  of  the  ligaments ;  flexion,  alteration  of  the  ligaments 
and  of  the  uterine  parenchyma  at  the  same  time.  Peritoneal 
adhesions  uniting  the  fundus  of  the  uterus  to  the  recto-uterine  cul- 
de-sae  are  generally  lax  and  filamentous  and  easily  destroyed.  At 
other  times  they  offer  great  resistance.     The  ovaries  and  tubes  are 


Posterior  Disp  lac  em  ents. 


275 


often  dislocated  by  uterine  deviation  and  may  frequently  be  found 
at  the  border  of  Douglas'  cul-de-sac.  It  is  probable  that  part,  at 
least,  of  the  reflex  nervous  phenomena,  often  grave,  extending  even 
to  paraplegia,  which  have  been  noted  in  some  retroflexions,  are  due 
to  the  pulling  on  the  appendages  and  not  to  the  problematic  com- 
pression of  the  nerves  of  the  sacral  plexus.  There  is  often  coinci- 
dent salpingitis;  it  is  even  the  rule  in  irreducible  retroversions 
and  this  resistance  to  reduction  comes  much  less  frequently  from 
adhesions  of  the  uterine  body  than  from  those  of  the  appendages 
to  the  pelvic  walls.  The  extension  of  perisalpingitis  is  the  origin 
of  these  adhesions  and  also  of  painful  or  indolent  indurated  nuclei, 
of  rapid  growth  and  disappearance,  which  are  often  observed  on 
the  posterior  surface  and  the  sides  of  the  retroflexed  body. 


Fig.  143. — Very  pronounced  retroti< 


Symptoms. — The  uterine  syndrome,  very  marked  reflex  nervous 
phenomena,  sterility ;  such  is,  in  brief,  the  summary  of  the  rational 
symptoms.  Constipation,  with  or  without  tenesmus,  is  particularly 
obstinate  and  Barnes  attributes  the  emanations  of  the  patient  to 
coprgemia.  But  this  has  a  much  more  complex  origin.  It  is  neces- 
sary to  insist  particularly  on  the  nervous  troubles  to  which  I  have 
already  alluded.  There  is  often  extreme  difficulty  in  walking,  out 
of  proportion  to  that  produced  by  simple  muscular  fatigue,  even 
simulating  paraplegia ;  multiple  neuralgias,  hysteriform  excitability, 
paroxysmal  cough,  dyspepsia,  etc.,  are  observed.  Schroeder  has 
noted  chorea;  Chrobale,  very  mtense  asthma;  Kehi-er,  aphonia; 
Sielki,  hystero-epilepsy ;  Kiderlin,  incessant  vomiting.  The  simple 
replacement  of  the  uterus  has  caused  rapid  disappearance  of  these 
grave  symptoms.  Sterility  ordinarily  follows  retroflexion.  Some- 
times fecundation  takes  place,  then  either  the  uterus  replaces  itself, 


276  Postericn-  Displacements. 

or  it  remains  iiexed  and  is  more  and  more  incarcerated  in  the  pelvis, 
giving  rise  to  grave  symptoms  which  are  studied  in  obstetrics  under 
the  head  of  retroflexion  of  the  gravid  uterus.  If  care  be  taken  to 
see  that  iuvohitiou  of  the  uterus  occurs  normally,  after  confine- 
ment, the  replacement  of  the  organ  can  sometimes  be  obtained 
spontaneously;  pregnancy  then  plays  a  true  therapeutic  role, 
■fthich  cannot  be  denied,  but  which  may  be  over-estimated. 

Diagnosis. — The  tumor  iu  the  posterior  cul-de-sac,  easily  recog- 
nized as'the  fundus  of  the  i;terus  by  bimanual  palpation,  the  absence 
of  resistance  in  the  anterior  cul-de-sac  in  the  situation  of  the  normal 
position  of  the  organ,  the  possibility  of  feeling  the  angle  uniting  the 
cervix  and  body — such  are  the  distinctive  characters  which  the  phy- 
sician will  seek.  Eectal  touch  is  here  indispensable.  Exploration 
with  the  sound  removes  the  last  doubts ;  it  should  be  conveniently 
curved  and  the  cernx  dra^n  down,  or  at  least  steadied  with  the 
volsella.  I  refer,  finally,  for  other  details,  to  the  diagnosis  of  retro- 
version. 

It  is  necessary  here  to  ascertain  the  degree  of  mobility  of  the 
uterus,  iu  order  to  determine  the  line  of  the  treatment.  Professor 
Trelat  di\-ides  retroflexions,  from  this  point  of  ^•iew,  into  three 
classes:  1.  Eeducible;  2.  Eesisting;  3.  Adherent.  These  different 
degrees  are  taken  into  account,  in  trying  replacement,  either  by  bi- 
manual manipulation,  or  by  the  sound,  by  estimating  the  resistance 
encountered  and  the  permanence  of  the  replacement. 

Treatment. — Is  it  necessary  to  treat  the  concomitant  metritis 
previously,  or  to  correct  the  deviation  at  once '?  Authors  have 
answered  this  question  in  different  ways.  I  believe  it  is  better 
fii'st  to  cure  the  inflammation  of  the  uterus  and  to  resori  to  the 
curette,  followed  by  injections,  and  in  catarrhal  or  chi-ouic  painful 
metritis,  to  amputation  of  the  cervix.  Eetroflexions  frequently  cease 
to  be  painful  after  the  cure  of  the  metro-salpiugitis,  and  even  a 
certain  degree  of  spontaneous  reduction  may  occur  from  the  invo- 
lution of  the  uterus.  It  is  well,  in  these  special  cases,  always  to 
resort,  before  curetting,  to  dilatation  with  tents,  as  these  will  at 
once  commence  a  momentary  correction  of  the  uterme  canal.  If, 
along  with  metritis,  acute  peri-metro-salpingitis  exists,  endeavors 
should  be  made  to  cure  it  by  appropriate  treatment  (hot  injections, 
baths,  appUcation  of  glycerine  tampons  against  the  cervix,  deriva- 
tives to  the  abdomen).  It  is  only  when  all  inflammatory  symptoms 
have  ceased,  when  the  culs-de-sac  are  no  longer  painful,  that 
replacement  should  be  attempted.  Then  the  reduction  should  be 
maintained.  The  opposite  method,  praised  by  PouUet,  appears  vei-y 
imprudent. 

Reduction  of  Retroflexion. — The  reduction  of  the  uterine 
deviation  may  be  made  iu  different  ways : 

1.  Genn-pectoral  position. — When  the  patient  assumes  the  genu- 


Posterior  Disjplacements.  %TJ 

pectoral  position,  the  limbs  slightly  separated  and  the  fourchette 
depressed  to  admit  the  air  into  the  vagina  (Fig.  144),  the  abdominal 
viscera  falls  toward  the  concavity  of  the  diaphragm  and  the  movable 
retroverted  or  retroflexed  uterus  is  drawn  into  its  natural  position. 
This  replacement  can,  however,  be  aided  by  keeping  the  vaginal 
wall  drawn  back  and  exercising  traction  on  the  posterior  cul-de-sac 
with  the  speculum  depressing  the  fourchette.  This  spontaneous 
atmospheric  replacement,  as  Courty  has  called  it,  constitutes  a 
valuable  procedure,  which  any  woman  can  easily  practice  daily, 
taking  this  posture  morning  and  evening. 


Fig.  144. — Reduction  of  a  retroversion  by  the  genu-pectoral  position. 

Tarnier  recommends  women,  where  they  take  this  position,  to 
introduce  a  small  wire- work  speculum  or  simply  a  syringe  nozzle 
into  the  vagina  to  facilitate  access  of  air  and  the  pushing  forward 
of  the  uterus.  E.  Mosher,  who  recently  insists  anew  on  treatment 
by  this  position,  makes  his  patient  introduce  the  finger  into  the 
vagina  and  press  on  the  anterior  surface  of  the  cervix  so  as  to  make 
the  uterus  swing  toward  the  front.  If  this  procedure  is  rarely 
sufficient  by  itself,  it  is  certainly,  especially  in  cases  not  wholly  in- 
tractable, a  valuable  aid  in  the  treatment  of  posterior  displacements. 
The  patient  should  also  be  advised  to  make  it  a  habit  to  sleep  on 
the  abdomen,  or  in  semi-prone  position. 

2.  Bimanual  replacement. — The  patient  must  be  placed  in  Sims' 
lateral  position  or,  if  necessary,  even  in  the  genu-pectoral  position ; 
two  or  thi-ee  fingers  of  the  left  hand  placed  in  the  posterior  cul- 
de-sac  or  in  the  rectum  push  the  cervix  backward  wdrile  the  right 
hand,  depressing  the  abdominal  walls  above  the  pubes,  seizes 
the  body  and  draws  it  forward  into  a  position  of  anteversion.  It  is 
necessary  to  exaggerate  the  new  position  to  overcome  the  tendency 
to  return  toward  retroversion.  This  manceuvre  is  much  facilitated 
by  fixing  the  cervix  with  the  volsella  and  drawing  it  down  slightly. 
Schultze  has  recommended,  in  difficult  cases,  the  introduction  of 
the  index  finger  into  the  previouely  dilated  uterine  cavity.    By  the 


278 


Posterior  Displacements. 


action  which  he  thus  exercises  directly  on  the  uterine  tissue,  he 
destroys  by  energetic  traction  the  posterior  adhesions  which  may  be 
an  obstacle  to  replacement.  He  minutely  describes  how  to  hberate 
the  uterus  from  adhesion  bands  which  hold  it  posteriorly  and 
laterally,  or  the  surface  adhesions  to  the  anterior  wall  of  the  rectum. 
Under  ansesthesia  the  ovaries  may  also  be  felt  and,  he  affirms,  theii- 
adhesions  broken  up.  This  bold  procedure  has  found  imitators,  but 
has  also  raised  opposition  (Schi'oeder).  It  cannot  be  doubted  that 
Schultze  has  had  remarkable  success  with  it,  but  if  inflammation  of 
the  tubes  exists,  it  may  prove  extremely  dangerous. 


Fig.  145.- 


-Bimanual  replacement  of  a  retroversion  or  a  retroflexion. 
Raising  up  the  uterus. 


3.  Replacement  with  the  sound. — This  is  the  method  generally 
employed  and  Schultze  himself  recommends  it  in  cases  where  the 
adhesions  to  be  overcome  do  not  offer  exceptional  resistance.  The 
operation  is  done  in  Sims'  lateral  position  or  the  genu-pectoral.  The 
metallic  sound,  which  must  be  large  and  resistmg,  is  first  introduced 
many  times  successively,  so  as  to  overcome  as  much  as  possible  the 
retroflexion  and  to  transform  it  momentarily  into  retroversion. 
Then,  making  the  sound  describe  a  semicircle,  its  tip  is  forced  to 
make  a  rotation  in  the  uterine  cavity,  which  will  carry  the  concavity 
of  the  sound  forward.  The  uterus  is  then  replaced,  but  in  retro- 
position  ;  to  brmg  it  forward  the  handle  of  the  hysterometer  is 
carried  toward  the  fourchette  (Fig.  147).     Thi-oughout  the  operation 


Posterior  Displacements. 


279 


Fig.  146. — Bimanual  replacement  of  a  retroversion  or  a  retroflexion. 
Placing  the  reduced  uterus  in  anteversion. 

spasmodic  efforts  must  not  be  made,  but  a  gentle  and  continuous 
pressure  should  be  maintained,  which  may  be  quite  firm  if  it  is  pro- 
gressive. It  is  well  to  precede  replacement  by  dilatation  with 
laminaria  tents  which  makes  the  structure  more  flexible ;  curetting  of 
the  uterus,  whose  mucosa  is  more  or  less  diseased,  should  also  be 
done  at  the  outset,  especially  at  the  angle  of  flexion.  Eeplacement  can 
sometimes  be  performed  in  one  operation.  At  other  times,  it  is 
best  to  do  a  little  every  two  or  three  days ;  after  each  the  degree  of 
replacement  obtained  must  be  maintained  by  carefully  placing  in 
the  posterior  cul-de-sac  tampons  of  antiseptic  gauze.  Finally,  a 
pessary  is  introduced.  The  most  simple  instrument  for  replacement 
is  the  uterine  sound.  I  prefer  it  to  any  of  the  different  repositors 
that  have  been  invented. 

Fixation  of  the  Replaced  Uterus. — To  this  end  may  be 
employed  prothetic  means  (pessaries)  or  different  operations. 

Pessaries. — The  number  of  pessaries  employed  for  the  treatment 
of  retroflexions  is  large  and  is  increasing  daily.  I  refer  for  the 
description  of  the  various  models  to  special  articles  and  confine 
myself  to  the  description  of  the  most  common,  wliich  are  also  the 


280 


Posterior  DispUwements 


Fig.  147. — Replacement  of  a  retroflexion  with  the  sound. 


^"^ 


Fig.  148. — Ring  pessarj'  in  place  in  a  case  of  reducible  retroflexion 
which  is  in  the  process  of  transformation  into  retroversion. 


Posterior  Displacements. 


281 


best.  A  simple  tampon,  conveniently  rolled  and  placed  in  the 
posterior  cul-de-sac  of  the  vagina,  is  a  means  of  support.  But  it  is 
much  better  to  apply  an  indif- 
ferent pessary  like  the  annular 
pessary,  which  may  sometimes 
incases  of  reducible  retroflexion, 
even  in  the  absence  of  surgical 
interference,  bring  about  the  re- 
placement of  the  uterus  by  the 
pressure  it  exercises  (Fig.  148). 
Finally,  a  better  means  of  sup- 
port is  Hodge's  double  curved  p-jQ.  i49._Hodge's  pessary  with  an  an- 
pessary  (Figs.  149, 150, 151).  The  te"0''  "°tch  to  avoid  compression  of  the 
1  .     .      ,  ^  J.         urethra. 

pessary  ought  to  be  chosen  tor 

each  case,  accordingto  the  size  of  the  vagina.  If  too  small,  it  is  of 
no  use ;  too  large,  it  becomes  intolerable.  If  the  perinseum  is  resist- 
ing, the  pessary  may  be  a  little  narrowed  at  the  lower  end  (Albert 


Fig.  150. — Introduction  of  a  Hodge  pessary  in  a  case  of  retroversion 
(this  should  be  previously  replaced). 

Smith's  pessary) ;  this  would  be  incon-\'enient  in  the  opposite  con- 
dition.     A  little  notch  in  the  anterior  part  avoids  pressure  upon  the 


282 


Posterior  Displace menifs. 


Tirether  (Fig.  149).  The  most  convenient  pessaries  are  those  made 
of  thick  copper  wire  covered  ^ith  rubber ;  theii'  form  can  be  quickly 
modified,  although  they  offer  sufficient  resistance ;  one  should,  in 
fact,  know  how  to  adapt  the  shape  of  the  instrument  to  each  indi- 
vidual case.  Hard-rubber  pessaries  ai-e  also  very  good.  They  can 
be  softened  in  hot  water  to  change  then-  form.  In  difficult  cases,  I 
generally  model  the  pessary  ^\ith  a  ring  of  flexible  tin,  and  when  I 
am  sure  that  it  is  adapted  to  the  special  case,  I  have  constnicted 
fi'om  this  model  au  aluminum  pessaiy,  which  has  the  advantage  of 
being  light  and  resisting,  but  the  vaginal  secretions  attack  it  and  it 
ought  to  be  fi'equently  renewed.  It  is  always  necessary  to  have  the 
inferior  extremity  rest  a  httle  above  the  meatus  urinarius. 


Fig.  151 . — Hodge  pessary  in  place  after  reduction  of  a  retrodeviation. 

Thomas  has  increased  the  thickness  of  the  posterior  arch  of 
Hodge's  pessary  to  prevent  its  resting  in  the  angle  of  the  reproduced 
retroflexion  and  has  accentuated  the  ciuwe  (Fig.  152). 

To  introduce  Hodge's  pessary  the  patient  should  lie  on  her  side. 
The  instrument,  coated  with  vaseUue,  is  presented  at  the  vulva  in 
such  a  manner  as  to  make  it  shp  along  one  of  the  lateral  sui'faces 
of  the  vagina ;  during  this  time  the  labia  are  first  dra^ni  apart,  then 
the  foui-chette  is  depressed  Mith  the  finger  (Fig.  150).  When  the 
pessary  has  passed  the  inferior  part  of  the  vagina,  it  can  easily  be 
tiirned  in  the  larger  superior  pari,  and  a  semispiral  ghding  move- 
ment is  made  upward  and  toward  the  back,  which  carries  it  to  the 
posterior  wall.  It  has  only  to  be  pressed  upon  at  the  siiperior  cuiwe 
^nth  the  hides  finger,  to  make  it  lodge  in  the  posterior  cul-de-sac. 
The  pessary  is  thus  placed  obliquely  in  the  vagina,  fi-om  above 
downward  and  from  behhid  forward.  The  abdominal  pressure  acts 
constantly  on  the  pehic  floor  and  under   spinal  muscular  strain 


Posterior  Displacements. 


283 


tends  to  press  back  the  pessary  to  the  horizontal  plane.  It  oscillates 
then  on  an  imaginary  axis  which  passes  through  the  middle  of  its 
transverse  diameter,  so  that  wliile  its  inferior  extremity  is  raised 
the  superior  is  lowered,  and  in  consequence  presses  upon  the  pos- 
terior wall  of  the  vagina.  The  posterior  cul-de-sac  is  then  so  much 
the  more  stretched  and  the  cer^'ix  the  more  drawn  back  as  the  intra- 
abdominal pressure  is  stronger.  At  the  same  time  the  body  is 
carried  wholly  in  front  if  the  retroflexion  has  been  previously 
reduced.  Finally,  it  is  useful  to  remark  that  even  when  this 
reduction  is  incomplete,  some  good  may  be  derived  from  the  use  of 
the  Hodge  pessary  and  even  from  a  simple  annular  pessary ;  it  acts 
then,  without  doubt,  only  by  limiting  the  mobihty  of  the  uterus. 


Fig.  152, — Thomas'  pessary  in  place  after  reduction  of  a  retrodeviation. 

The  cradle  pessary,  or  a  simple  curve,  much  recommended  by 
Olshausen  and  Schroeder,  has  the  advantage  of  not  coming  as  low 
as  Hodge's,  and  also  of  supporting  the  anterior  waU  of  the  vagina ; 
it  is  therefore  specially  useful  in  cases  where  there  also  exists  a 
little  relaxation  of  tliis  wall.  But  it  has  a  less  powerful  action  than 
Hodge's  lever  pessary  with  double  curve  (Fig.  153).  Provided  the 
patient  takes  vaginal  injections  twice  a  day,  she  may  wear  the 
pessary  two  or  three  months.  At  the  end  of  this  time  it  should  be 
withdrawn  and  the  position  of  the  uterus  noted.  If  it  remains  in 
anteversion,  the  pessary  may  be  removed ;  otherwise  it  should  be 
replaced.  The  accidents  which  have  been  observed  where  pessaries 
have  been  left  for  a  longtime  in  place,  have  occurred  in  cases  where 
these  instruments  have  remained  for  years  in  the  vagina  without 
cleansing. 

The  foregoing  pessaries  act  indirectly  on  the  cervix  by  tension  on 
the  neighboring  parts.     Another  land  of  pessary  comprises  those 


284 


Posterim'  Displacements. 


which  have  a  direct  action  on  the  organ.  Schultze  apphes  figure- 
of-eight  pessaries,  which  hold  the  cervix  itself  and  draw  it  back- 
ward ;  they  are  formed  by  a  copper  wu'e  covered  -nith  rubber.  The 
pessary  is  chosen  so  that  the  superior  ring  of  the  eight  embraces  the 
cervix  mthout  strangling  it,  wliile  the  inferior  ring  is  in  proportion 
to  the  capacity  of  the  vagina  and  to  the  opening  of  the  ischio-pubic 
arch.  These  pessaries  are  better  borne  by  nulUparous  women  ui 
whom  the  vagina  ofifers  sufficient  resistance  so  that  a  support  need 
not  be  sought  below. 


Fig.  153. — Cradle  pessary  in  place  after  reducUon  of  a  retrodeviation. 

Nearly  related  to  the  figure-of-eight  pessary,  is  the  ingenious 
pessary  of  Landowski,  of  malleable  tin,  which  permits  the  T  stem 
to  be  tui-ned  in  any  direction  according  as  the  pessary  is  to  be 
applied  to  an  anteversion  or  retroversion.  In  the  latter  case  the 
stem  is  bent  from  behind  toward  the  front  and  the  anterior  wall 
of  the  vagina  fits  its  concavity;  this  stem  is  supported  on  the 
symphysis  pubis,  embracing  m  its  curved  extremity  the  structures 
which  lie  beliind  the  pubis,  and  whose  thickness  varies  much  in 
different  subjects ;  the  ring  surrounds  the  cervix.  We  must  be 
well  assured,  by  rectal  touch  before  applying  it,  that  the  fundus 
of  the  uterus  is  replaced ;  then  the  pessary  being  placed,  the  patient 
is  made  to  walk,  to  sit  down  and  to  lie  down,  to  make  sure  it  does 
not  inconvenience  her,  in  which  ease  we  must  resort  to  a  smaller 
instrument.  'When  the  malleable  pessary  has  been  well  home,  an 
inflexible  pessary  of  aluminum  is  made  on  its  model. 

When  the  perinseum  is  very  flabby,  the  vagina  large  and  relaxed, 
Schultze  employs  the  sleigh  pessary  ;  which  is  very  hke  the  pessary 
proposed  more  recently  by  YuUiet.  Fritsch  has  combined  Schultze's 
pessary  with  Hodge's  (he  uses  instruments  of  hard  rubber) ;  it  is 


Posterior  Displacement's. 


285 


especially  the  in  first  days  after  replacement  that  he  uses  it,  after 
which  he  replaces  it  by  a  Hodge's  pessary  very  much  curved.  All 
these  pessaries  are  more  easily  applied  in  Sims'  position. 


Fig.  154. — Figure-of-eight  pessary  in  place  after  reduction  of  a  retrodeviation. 

Pessaries,  whose  support  is  external,  have  been  praised,  as  in 
hysterophores  employed  for  prolapsus.  They  are  inconvenient  and 
uncertain.  The  use  of  intrauterine  stem-pessaries  was  in  gi'eat 
favor  some  years  ago.  They  may  be  useful  for  maintaining  a 
replacement  effected  with  difficulty  for  some  days,  particularly  as 
auxiliaries  after  operative  replacements.  Courty  places  a  galvanic 
uterine  support  for  some  hours  after  each  replacement  with  the 
sound,  once  or  twice  a  week.  Alexander  also  maintains  the  utems 
in  anteversion  with  the  intrauterine  stem-pessary  after  the  shorten- 
ing of  the  round  ligaments.  These  are,  I  believe,  the  only  two 
useful  applications  of  intrauterine  stem-pessaries  in  retroflexion. 
The  new  models  of  Chambers,  Meadows,  and  others,  ingenious  as 
they  are,  have  no  more  value  than  the  old  ones. 

Whatever  the  pessary,  there  is  a  great  number  of  cases  in  which 
their  retention  is  absolutely  impossible.  According  to  very  careful 
personal  observations  of  Sanger,  made  on  fifty-seven  cases  in  his 
private  practice,  he  has  obtained  only  seven  cures,  being  10.6  per 
100,  by  means  of  pessaries;  twenty-seven  ameUorations,  being  40.9 
per  100 ;  in  fifteen  cases,  being  27.7  per  100,  no  local  result,  although 
there  was  relief  of  the  subjective  symptoms. 

Sometimes  it  is  the  extreme  mobility  of  the  organ,  at  other  times 
the  size  and  laxity  of  the  vagina,  the  relaxation  of  the  perinseum, 
which  are  the  cause  of  the  failure  of  pessaries.  In  the  latter  case 
they  may  be  tried  in  conjunction  with  the  use  of  a  perinseal  pad. 


286  Posterior  Displacements. 

^Thich  often  helps  the  patient  greatly.  11'  there  is  at  the  same  time 
prolapsus  of  the  uterus  or  of  the  vagina,  plastic  operations,  which 
will  be  described  in  connection  with  these  affections,  here  find  theii' 
place  and  afford  a  support  for  the  treatment  of  the  displacement 
by  a  pessary.  The  patient  should  always  be  assisted,  especially  if 
the  abdomen  is  large,  by  an  abdominal  belt  which  sustains  the 
weight  of  the  viscera. 

However  this  may  be,  many  women  cannot  be  cured  by  prothetic 
means.  We  are  justified  then  in  resorting  to  an  operation.  There 
are  two,  especially,  which  merit  a  detailed  description — shortening 
of  the  round  ligaments  and  abdominal  hysterorraphy.  I  shall  treat 
in  detail  the  different  methods  of  vaginal  hysteropexy,  etc. 


Fig.  155. — The  round  ligament  at  the  external  inguinal  ring. 

The  Alquie- Alexander- Adams  operation. — The  idea  of  replacing  or 
of  uplifting  the  uterus  by  shoi-tening  the  round  ligaments  belongs  to 
Alquie,  of  MontpeUier.  Two  English  surgeons,  Alexander  and 
Adams,  have  the  credit  of  taking  this  up  anew  and  of  performing  the 
operation  almost  simultaneously,  but  it  is  only  just  to  add  to  their 
names  that  of  Alquie.  Shortening  of  the  round  ligaments  has  been 
employed  both  for  retroflexion  to  maintain  its  normal  position  and 
for  prolapsus  uteri.  The  operation  was  first  received  very  coldly  in 
England,  Germany  and  France.  It  was  declared  after  insufficient 
and  unfortunate  researches  that  the  round  ligaments  were  to  be 
found  only  with  gi-eat  difficulty  outside  the  internal  inguinal  open- 
ing. A  reaction  then  took  place  and  the  operation  has  to-day  many 
partisans,  although  its  precise  indications  and  its  advantages  are 
far  from  being  settled.  I  wiU  describe  the  technique,  basing  it  both 
on  Alexander's  memoir  and  on  my  o^mi  experience.  This  operation 
should  always  be  preceded,  1  believe,  by  curetting  as  a  preliminary. 

FiEST  AND  Second  stages. — Uncovering  the  ligaments. — Search 


Posterior  Displacements.  287 

for  the  pubic  spine ;  cut  parallel  to  the  crural  arch,  over  an  extent 
of  five  centimetres,  as  far  as  the  aponeuroses ;  with  the  finger  the 
weak  point  corresponding  to  the  external  inguinal  ring  is  found ;  this 
is  dissected  with  care  to  lay  bare  the  pillars,  as  well  as  the  inter- 
columnar  or  arciform  fibres  which  limit  it  above  and  externally. 
The  cellular  lamella  which  extends  between  the  pillars  is  incised, 
and  immediately  there  is  seen  a  fine  and  yellow  ball  of  fat  pro- 
jecting from  the  orifice.  A  nerve  branch  (genital  branch  of  the 
genito-crural  nerve)  is  pushed  aside  and  the  round  "ligament  is 
sought  mth  a  grooved  director.  It  presents  the  appearance  of  a 
reddish  cord,  sometimes  fimbriated  at  its  inferior  extremity.  As 
soon  as  it  is  recognized,  it  is  seized  with  the  forceps  and  denuded 
with  a  blunt  instrument.  This  done,  the  wound  is  covered  with  an 
antiseptic  tampon  and  the  same  procedure  is  repeated  on  the  other 
side,  covering  it  also  while  occupied  with  the  third  stage. 

Thied  stage. — Replacement  of  the  uterus. — The  replacement  is 
easily  done  by  an  assistant,  using  the  sound  as  Alexander  prefers. 
While  an  assistant  accomplishes  the  reposition  with  the  aid  of  the 
bimanual  method,  the  surgeon  uncovers  the  wounds  and,  seizing 
the  incompletely  denuded  round  ligaments,  either  with  a  spatula 
or  by  snipping  with  the  scissors,  he  separates  those  fibrous  bands 
which  unite  them  to  the  contiguous  parts.  Attempt  is  made  to 
liberate  the  ligament  as  far  as  the  inguinal  orifice,  that  is  to  an 
extent  of  about  ten  centimetres.  A  length  of  four  to  five  centimetres, 
which  appears  sufficient  to  some  surgeons,  accomplishes  only  an 
apparent  replacement.  To  avoid  wounding  the  serosa,  Duplay  has 
proposed  to  place  a  catgut  ligature  around  the  most  distant  portion 
of  the  intra-inguinal  segment  that  has  been  uncovered.  If  the 
serous  membrane  has  been  di'awn  down  like  a  glove-finger,  the 
ligature  closes  this  cul-de-sac.  I  do  not  make  use  of  tlfis  procedure. 
It  is  necessary  to  draw  on  the  two  ligaments  at  the  same  time  and 
to  an  equal  extent.  The  ligaments  yield  easily  with  a  moderate 
traction,  especially  if  the  reduction  of  the  uterus  is  assisted  with 
the  sound.  The  facility  with  which  they  may  be  dra-wn  out  might 
lead  the  inexperienced  operator  to  believe  that  he  had  ruptured 
them  deeply.  A  resistance  is  felt  as  soon  as  the  traction  affects  the 
uterus.  This  traction  then  transmits  oscillations  to  the  sound  in 
the  organ. 

Fourth  stage. — Suture  of  the  shortened  round  ligaments;  Occlusion 
of  the  wound. — The  surgeon  then  assigns  to  an  assistant  the  duty  of 
keeping  the  ligaments  moderately  tense  while  they  are  fixed.  A 
curved  needle  threaded  with  silk  is  pushed  through  the  external 
pillar  and  the  ligament  toward  its  superior  border,  in  such  a  way 
as  to  solidly  unite  to  the  external  inguinal  opening  that  portion 
which  will  become  the  extremity  of  the  round  ligament.  A  similar 
second  buried  suture  is  placed  on  the  inferior  border  of  the  ligament. 


288  Posterior  Displacements. 

All  that  part  of  the  ligament  outside  these  sutui-es  is  then  excised. 
If  the  arciform  fibres  have  been  divided  and  the  inguinal  canal 
opened  a  Uttle,  it  is  closed  with  catgut  sutures.  Even  if  tins  incision 
has  not  been  made,  I  always  close  the  inguinal  ring  with  a  continu- 
ous suture  of  catgut,  forming  thus  the  deepest  plane  of  the  buried 
suture  in  superposed  rows,  with  which  I  close  the  wound.  It  is 
wholly  useless  to  place  a  drainage  tube  if  the  search  has  not  been 
difficult  and  if  the  wound  is  clean.  Antiseptic  dressing  is  applied, 
held  with  moderate  pressure. 

Fifth  stage. — Alexander  considers  it  essential  to  keep  the  uterus 
in  place  during  convalescence  with  a  Hodge  pessary  and  an  intra- 
uterine stem-pessary.  The  first  ensures  anteversion,  the  second 
overcomes  flexion.  The  ligaments  are  thus  protected  from  traction. 
The  pessary  should  be  retained  for  a  month,  during  which  time  the 
patient  remains  in  bed.  I  have  discarded  the  intrauterine  stem, 
but  I  believe  it  is  useful  to  support  the  ligaments,  and  thus  reheve 
them,  either  with  a  Hodge  pessary  or  with  antiseptic  tampons 
frequently  renewed. 

Gravity  of  the  operation ;  Results ;  Indications. — At  the  close  of  his 
memoir,  Alexander  cites  twenty- six  cases  of  retroflexion  or  retro- 
version operated  on  (to  June,  1885)  with  constant  success.  Though 
it  is  evidently  a  benign  operation,  Alexander  states  that  death  may 
occur  under  exceptional  cii'cumstances  as  in  any  surgical  operation, 
however  small.  He  knows  of  three  cases,  one  of  his  own.  Among 
numerous  other  observations  Hanington  has  collected  statistics  of 
one  hundred  and  forty  eases,  from  twenty-one  operators,  with  three 
deaths.  In  resume  it  appears  that  the  Alquie-Alexander  operation 
is  capable  of  giving  excellent  and  permanent  results  in  retroflesion 
of  the  uterus.  In  simple  cases  the  pessary  may  be  preferred,  but  in 
cases  in  which  the  pessary  does  not  apply,  where  it  supports  with 
difficulty  and  only  maintains  the  uterus  incompletely,  shortening 
the  round  ligaments  is  a  valuable  resource.  Patients  can  thus  be 
cured  that  we  have  been  unable  to  reheve  before.  Trelat  clearly 
formulates  the  rule  that  shortening  of  the  round  hgaments  appears 
to  be  the  operation  that  is  dh'ectly  indicated  to  maintain  in  ante- 
version  a  uterus,  previously  fixed  in  adherent  retroflexion,  that  may 
be  mobilized  by  treatment,  but  that  it  is  impossible  to  keep  in 
position  by  pessaries.  Still  more,  as  retrode\dations  constitute,  in 
his  eyes,  a  certain  menace  for  the  future,  in  view  of  the  compli- 
cation of  metritis  and  of  salpingitis,  he  believes  it  to  be  a  good  pre- 
ventive operation  even  in  absolutely  indolent  retroversions.  This 
precept  extends  the  field  of  the  operation  too  much ;  I  incline  rather 
to  the  opinion  of  Munde,  who  reserves  shortening  of  the  round  hga- 
ments for  painful  and  easily  reducible  displacements. 

Colpohysterorrhaphy  or  vafjinal  hjistcrorrhaphy . — The  first  attempts 
to  fix  the  uterus  in  position  through  the  vagina,  after  reduction  of  a 


Posterior  Displacements.  289 

deviation,  are  of  very  old  date.  They  vary,  from  cauterization  mth 
the  actual  cautery,  in  such  a  manner  as  to  produce  a  cicatricial 
contraction  on  the  side  opposite  to  the  deviation,  down  through  the 
various  procedures  of  excisions  and  sutures  of  the  vaginal  culs-de- 
sac,  to  the  complete  and  methodical  operations  of  to-day. 


Fig.  156. — Vaginal  hysteropexy.     Schucking's  operation  (de  Pyrinont). 

Richelot  has  recently  advised  a  method,  originated  by  Nicoletis, 
intended  to  restore  the  uterus  to  position,  by  taking  a  point  of 
support  from  the  posterior  vaginal  wall  and  the  perinseum.  Supra- 
vaginal amputation  of  the  cervix  is  fu'st  done.  Then,  at  the 
posterior  portion,  three  catgut  sutures  are  passed,  including  the 
vagina  and  the  uterine  stump,  in  such  a  manner  that  they  come  out 
through  the  opening  of  the  uterine  cavity.  These  tlu-ee  threads  are 
median.  At  the  side,  to  the  right  and  to  the  left,  two  others  are 
passed,  taking  in  the  posterior  wall  of  the  vagina  and  coming  out 
on  the  anterior  edge  of  the  stump,  so  that  the  posterior  vaginal 
wall  encroaches  on  this  portion  in  applyuig  itself  to  the  uterine 
section.  The  coaptation  is  completed  by,  superiicial  stitches.  This 
surgeon  thus  proposes  to  bring,  all  of  the  vaginal  insertion  toward 
the  anterior  portion  of  the  stump  so  that  it  wUl  draw  the  fundus 
forward  (Fig.  157).  However,  I  beheve  this  to  be  a  delusion.  The 
constant  distensibility  of  the  vagina  and  the  frequent  laxity  of  the 
perinseum  reduce  this  procedure  to  an  ingenious  theoretical  con- 
ception. The  good  results  obtained  are  simply  due  to  the  action  of 
the  cervical  amputation  on  the  metritis. 

Pean,  under  the  term  vagino-fixation,  has  described  the  following : 
The  recto-  and  vesico-vaginal  septa  are  seized  with  strong  forceps 
and  the  vaginal  walls  separated.  Without  any  freshening  a  needle 
carries  a  suture  from  before  backward  through  the  lateral  wall  of 
the  vagina,  in  all  its  extent,  comprising  as  great  a  thickness  of 


290 


Posterior  Displacements. 


submucous  tissue  as  possible.  Loops  of  the  sutures  are  thus  passed 
to  the  whole  height  of  the  vagina  at  two  centimetres  from  each 
other.  The  vaginal  wall  is  thus  sutured  to  the  corresponding  wall 
of  the  pelvis.  The  sutures  are  left  in  place  and  by  cutting  the 
tissues  produce  transverse  cicatrices.  TMs  operation  does  not 
exclude  perineorrhaphy  as  a  supplementary  operation,  and  the 
employment  of  a  pessary  is  useful.  Pean  has  only  applied  this 
method  once  and  has  not  stated  its  ultimate  result.  A  jiriori  this 
procedure  appears  dangerous  and  of  but  little  efficacy. 


Fig.  157. — Vaginal  hysteropexy.  Method  of  Nicoletis.  i.  Uterus  in  retroversion, 
o  i,  line  of  the  section ;  r  a",  vaginal  walls.  2.  Completed  suture.  3.  Uterus  replaced. 
a,  insertion  of  the  two  vaginal  walls  on  the  anterior  border  of  the  stump.  4.  Uterine 
stump ;  passage  of  the  three  median  sutures,  a,  vaginal  wall ;  b,  anterior  border  of 
the  stump;  c,  uterine  orifice.  5.  Fixation  of  the  posterior  vaginal  wall  to  the  anterior 
border  of  the  stump.     6.  Fixation  of  the  posterior  vaginal  wall  to  the  uterine  orifice. 

Pelvic  colpohysteropexy. — Freund  has  performed  this  operation 
only  once.  He  makes  a  large  opening  in  the  posterior  cul-de-sac 
of  the  vagina,  opens  the  peritonseum  and  sutiires  the  posterior 
surface  of  the  supravaginal  portion  of  the  cervix  to  the  serous 
reflexion  situated  above  the  promontory  in  the  neighborhood  of  the 
utero-sacral  ligaments.  He  exercises  gi-eat  care  to  avoid  injuring 
the  rectum.  Finally  a  strip  of  iodotorm  gauze  is  placed  in  Douglas' 
cul-de-sac  and  the  vaginal  wound  is  narrowed.  Later  the  peri- 
useum  is  repaired  if  necessary.  It  does  not  appear  that  this 
operation  should  be  more  benign  and  more  efficacious  than  abdomi- 
nal hysterorrhaphy.  The  majority  of  the  procedures  for  vaginal 
hysterorrhaphy  have  faults.  They  act  directly  on  the  fundus  of 
the  uterus  and  fix  the  organ  to  mobile  and  distensible  structui'es. 


Posterior  Displacements.  291 

The  same  criticism  does  not  apply  to  suture  of  the  uterus  to  the 
abdominal  wall. 

Gastro-hysterorrhajyhy  (ventro-hysterorrhaphy,  gastro-hysterosyn- 
synaphy) . — In  fixing  the  pedicle  of  ovarian  cysts  outside  the  abdo- 
men, the  favorable  effects  of  this  procedure  on  displacements  of 
the  uterus  have  been  noted,  and  from  this  arose  the  idea  of  fastening 
this  organ  to  the  abdominal  wall,  through  the  intervention  of  the 
broad  Hgaments,  with  or  without  ablation  of  the  ovaries,  or  by  the 
fundus.  The  first  operation  of  tliis  kind  is  credited  to  Koeberle,  in 
1869.  Since  then  a  number  of  isolated  cases  have  been  reported, 
but  Olshausen  was  the  first  to  systematize  the  operation.  Soon  after 
Howard  A.  Kelly  published  ijiteresting  observation  of  a  retroflexion 
cm'ed  by  ablation  of  the  ovary  and  fixation  of  the  pedicle  to  the 
abdomen.  This  he  foUowed,  in  1888,  with  a  new  paper,  collecting 
new  facts.    Since  then  a  large  number  of  cases  have  been  reported. 


olshausen  and  Sanger. 


Operative  technique. — Three  principal  methods  and  various 
secondary  procedures  may  be  mentioned. 

1.  Indirect  fixation  (Koeberle,  Klotz). — The  ovary  or  the  tube  being 
removed  first,  the  pedicle  is  fixed  in  the  abdominal  wall.  Klotz 
attaches  much  importance  to  the  use  of  a  glass  tube,  beliind  the 
uterus,  reaching  to  Douglas'  cul-de-sac,  which  is  withdrawn  early  and 
which  serves  to  increase  the  adhesions.  Tliis  procedure  has  the 
disadvantage  of  sacrificing  the  ovary  and  also  of  making  torsion  of 
the  uteiiTs.    It  has  not  always  proved  successful. 

2.  Direct  lateral  fixation  of  the  body  of  the  uterus  (Olshausen, 
Sanger).— The  sutures  are  placed  on  each  side,  not  on  the  fundus, 
but  on  the  limits  of  the  uterus,  along  its  borders.  Silk- worm  gut  is 
used.  Three  are  made  on  each  side,  taking  care  to  include  in  the 
suture  only  the  anterior  serous  fold  and  not  to  wound  the  tube  or  the 
epigastric  artery  (Figs.  158  and  159).  This  method  has  the  disad- 
vantage that  it  forms   an  opening  between  the  uterus  and  the 


292 


Posterior  Displacements. 


abdomiual  ■nail,  which  exposes  the  patieut  to  the  ilaiiger  of  internal 
strangulation.  Kelly's  method  closely  resembles  that  of  Olshausen 
and  does  not  merit  special  description.  He  fixes  the  coruna  to  the 
parietal  serosa  after  ablation  of  the  ovary. 

3.  Direct  mcdinn  firation  of  the  hody  of  the  uterus  (Leopold,  Gzeiniy, 
and  others). — Leopold  fixes  the  fundus  of  the  uterus  to  the  ab- 
dominal wall.  The  abdomen  having  been 
opened,  and  the  utems  replaced  after 
separating  its  adhesions,  a  strong  needle 
thi-eaded  with  silk  is  passed  tlu'ough  the  en- 
tke  abdominal  wall  to  the  level  of  the  fun- 
dus. It  then  penetrates  into  the  uterine 
tissue  at  the  highest  paii  of  the  anterior 
surface  on  a  line  uniting  the  insertion  of 
the  two  round  Ugaments.  The  needle  passes 
under  the  serosa  and  the  supei-ficial  layer 
of  the  muscular  tissue  to  an  extent  of  one 
centimetre,  then  it  penetrates  the  abdominal 
wall  again,  and  this  time  from  behind  for- 
FiG.  159.— Gastro-hystero-  ^ard,  ou  the  other  Hp  of  the  wound.  A 
pexy.    Method  of  Olshausen  second  sutiu'e  is  placed  above  this,  on  a 

of  Sanger.      Profile   view   of    ,  ,.  ...        ,■,       .  ,.  ,  , , 

the  suture,  tr,  tube;  Ir,  round  transverse  hue,  irmtmg  the  msertions  of  the 
ligament;  lo,  ovarian  liga-  tubes,  taking  in  an  extent  of  two  centi- 
'°^°''  metres,  and  a  third  still  a  little  above  in  the 

same  marmer  (Fig.  1601.  To  make  adhesions  more  certain  at  this 
level,  Leopold  lightly  scrapes  vnXh.  the  back  of  the  knife  the  sui-face 
of  the  peritoneal  covering  of  the  uterus  in  the  space  that  these 


Fin.  160. — Gastro-hysteropexy.     Leopold's  method. 

sutures  circumscribe.  This  scraping  is  intended  to  cause  fi-eshen- 
ing  of  the  surface,  without  lileeiling,  by  simply  removing  the 
epithelium.  Then  the  lips  of  the  abdominal  wound  are  closed  at 
this  level,  and  the  three  sutures  tied  above  the  abdominal  waU,  in 


Posterior  Displacements. 


293 


such  a  manner  that  the  anterior  surface  of  the  uterus  is  exactly 
applied  at  this  point  to  the  parietal  peritonseum.  The  rest  of  the 
wound  is  then  closed  above  and  below.  The  sutures  of  the  uterus 
are  removed  at  the  end  of  twelve  or  fifteen  days.  By  not  using 
buried  sutures,  Leopold  thinks  that  the  adhesions  are  more  lax 
and  cause  less  obstruction  to  the  bladder.  A  Hodge  pessary  is 
placed  in  position  for  a  month  to  reheve  the  strain  on  the  sutures 
and  to  maintain  the  acquired  position. 


Fig.  162. — Gastro-hysteropexy.     Terrier's  method. 

Czerny  traverses  the  anterior  wall  near  the  fundus  with  a  strong 
needle  thi-eaded  with  sublimated  catgut  (he  first  used  chromic  cat- 
gut). The  needle  first  passes  through  the  aponeurosis  of  the  ab- 
dominal wall  except  the  cellular  tissue  and  the  skin  (Fig.  162). 
These  threads  being  tied  constitute  buried  sutures,  above  which  the 
skin  is  brought  together. 


294 


Posterior  Thsplacements. 


I  use  for  hysterorrhapliy  the  overcast  suture,  which  I  always 
employ  in  wounds  of  any  extent.     My  technique  is  as  follows : 

First  stage. — Incision  of  the  ahdominal  wall,  on  the  median  hue, 
of  eight  centimetres,  beginning  two  finger's  breadth  above  the  pubes. 

Second  stage. — Introduction  of  the  index  and  middle  lingers  of 
the  right  hand  iii  the  wound ;  search  for  and  liberation  of  the  fundus 
of  the  uterus,  bringing  it  forward ;  during  this  time  it  may  be  useful 
to  have  an  assistant  lift  the  organ  up  with  his  fingers  in  the  vagina. 

Third  stage. — Pro%'isional  fixation  of  the  fundus  of  the  uterus 
with  a  volsella  placed  very  superficially  on  the  median  part  of  the 
fundus,  where  the  jaws  cause  no  haemorrhage.  They  are  entrusted 
to  an  assistant,  who  thus  lifts  the  organ  up.  A  Hagedoru  needle, 
thi-eaded  with  fine  but  strong  shk,  places  two  stitches  in  the  lower 
part  of  the  wound,  compassing  the  whole  of  the  sero-fibro-mucular 
plane  of  the  abdominal  wall  ui  such  a  way  as  to  form  a  point  of 
departm-e.  From  this  there  is  made  a  rapidly-ascending  overcasting, 
in  the  form  of  a  spiral,  traversing  successively  aU  the  deep  parts  of 
the  wound  (skin  and  cellular  tissue  excepted)  and  the  superficial 
layers  of  the  uterus  on  its  median  part.  Thi'ee  to  fom-  stitches  are 
sufficient.  As  soon  as  the  uterus  is  thus  fixed  to  the  abdominal 
wall  the  silk  suture  is  completed  (Fig.  163) . 


Fig.  163. — Gastro-hysteropexy.     The  author's  method.     U,  uterus  ;P, 
peritonaeum;   M,  musculo-aponeurotic  layer. 

Fourth  stage. — The  rest  of  the  wound  is  closed  by  an  overcasting 
of  catgut  in  two  supei-posed  rows.  Two  silk  sutures  comprise  the 
skin  and  the  cellular  tissue  and  a  superficial  row  of  continuous  cat- 
gut stitches  terminates  the  operation. 

Prognosis  of  (lastro-hystcrorrhaplnj. —  According  to  the  results  so 
far  published  the  operation  has  lieen  followed  by  very  few  deaths. 


Posterior  Displacements.  295 

It  does  not  exceed  in  gravity  an  uncomplicated  laparotomy,  which 
really  is  a  benign  operation.  There  is  no  doubt,  however,  that  the 
risks  are  increased  when  it  becomes  necessary  to  liberate  strong 
adhesions  about  the  uterus  and  in  particular,  adhesions  of  surfaces. 
These  are  the  only  cases  in  which  drainage  is  useful.  Experience 
has  proven  that  the  bladder  is  not  compromised.  Micturition  is  not 
interfered  with,  at  least  not  permanently.  The  cures  produced 
appear  permanent  in  some  cases  but  in  others  again  there  has  been 
a  return  of  the  prolapsus  or  of  the  retroflexion. 

A  question  that  it  is  important  to  solve  by  other  than  theoretical 
considerations,  is  the  effect  which  the  position  of  the  uterus  sutured 
to  the  abdomen  may  have  on  pregnancy.  WiU  the  adhesions  be 
destroyed  ?  Will  pregnancy  be  interrupted  by  the  obstruction  to 
the  development  of  the  uterus  or  will  the  organ  free  itself  from  its 
new  attachment  ?  One  of  the  reasons  for  which  Olshausen,  Sanger, 
and  others,  have  adopted  suture  of  the  border  and  not  of  the 
anterior  surface  was  this  fear  of  obstructing  the  development  of  the 
uterus  during  pregnancy.  But  experience  has  refuted  these  theo- 
retical objections  to  some  extent.  Sanger  and  Eoutier  report  cases 
of  pregnancy,  following  the  operation,  which  went  to  full  term 
without  accident.  However,  Kustner  has  noted  two  abortions 
attributable  to  the  operation. 

Indications  for  gastro-hysteroirhaphy  in  cases  of  retroversion. — 
Should  we,  with  Sanger  and  Leopold,  assume  the  absolute  safety  of 
antiseptic  laparotomy  and  perform  tliis  operation  even  for  cases  of 
reducible  retroversion?  This  seems  to  me  a  mistake.  The  short- 
ening of  the  round  ligaments  offers  too  valuable  a  resource  to  be 
neglected  in  these  cases.  When  two  operations  are  capable  of  giving 
equally  good  results  the  more  grave  should  be  resorted  to  only  after 
having  vainly  attempted  the  more  benign.  Now,  in  spite  of  the 
progress  of  abdominal  surgery,  it  cannot  be  claimed  that  opening 
the  peritoneum  and  suture  of  the  uterus  does  not  expose  the 
patient's  life  more  than  a  superficial  incision  and  suture  of  the 
shortened  round  ligaments.  But  if  I  condemn  gastro-hysterorrhaphy 
made  at  once  for  a  painful  mobUe  retroversion,  that  does  not  respond 
to  a  pessary,  before  having  tried  Alexander's  operation,  I  beUeve  it 
becomes  legitimate  when  the  latter  procedure  has  failed.  It  is  more 
rational,  more  certain,  and  perhaps  less  perilous  than  the  operations 
for  vaginal  hysterorrhaphy.  It  is  certainly  preferable  to  extirpation 
of  the  organ  tlii'ough  the  vagina. 

Finally,  the  principal  indications  for  abdominal  hysterorrhaphy 
appear  to  reside  in  cases  of  irreducible  retroflexions,  where  false 
membranes  and  adhesions,  that  cannot  be  overcome  under  cliloro- 
form,  hold  the  fundus  in  Douglas'  cul-de-sac.  When,  under 
anaesthesia,  the  uterus  is  irreducible  by  external  manoeuvres  aided 
by  the  sound  or  the  repositor,  when,  after  dilatation,  the  finger  in 


296  Posterior  Displacements. 

the  uterus  cannot  effect  replacement,  there  are  two  courses  to 
pursue.  In  one  there  will  be  no  new  attempts  at  replacement,  and 
only  palliative  treatment  directed  to  the  sjanptoms  will  be  employed ; 
in  the  other,  if  the  intensity  of  the  morbid  symptoms  demand  it, 
we  may  have  recourse  to  laparotomy  to  liberate  and  to  fix  the 
uterus. 

When  in  the  course  of  a  laparotomy  made  for  a  fibroid,  an  ovarian 
tumor,  an  inflammatory  condition  of  the  appendages,  etc.,  the  uterus 
is  found  in  retrode^dation,  and  when  the  ablation  of  the  appendages, 
as  often  happens,  does  not  bring  it  forward,  spontaneously,  the 
indication  is  to  profit  by  the  occasion  to  make  a  hysterorrhaphy 
to  replace  this  organ.  If  a  pedicle  be  at  disposal  it  can  be  brought 
into  the  abdominal  wound  and  sutured  there.  I  believe,  however, 
that  it  would  be  better  not  to  stop  at  this,  but  to  pass  also  one  or 
two  sutures  imder  the  most  superficial  layer  of  the  fundus  of  the 
utems,  or  of  its  anterior  surface,  on  the  median  part,  to  assure  a 
good  position  to  the  organ.  Another  indication  of  laparotomy, 
which  may  indirectly  furnish  the  occasion  for  this  secondary  fix- 
ation, relates  to  cases  where  there  exist  sharp  pains  and  painful 
reflexes  fi-om  the  appendages,  whether  these  organs  are  simply 
prolapsed  (mobile  retroflexions)  or  covered  by  adhesions  (irreducible 
retroflexions)  or  attacked  by  inflammation.  Sanger  and  Leopold 
have,  in  the  latter  case,  combmed  castration  with  gastro-hysteror- 
rhaphy.  The  latter  is  often  suflicient  in  simple  prolapsus  of  the 
ovary.  It  even  becomes  a  conservative  operation  then,  for  the 
reflex  phenomena  disappear  by  the  fixation  of  the  uteii;s,  becoming 
thus  a  fortunate  substitute  for  Battey's  operation. 

I  will  briefly  indicate  the  modifications  of  abdominal  hysteror- 
rhaphy which  have  a  particular  interest,  although  they  appear  to 
me  inferior  to  those  I  have  described. 

SJio^-teningthe  iitero-sacral  ligament  hy  laparotomy. — This  procedure, 
proposed  by  Kelly,  consists  in  passing  a  suture  on  each  side  of  the 
rectum,  in  the  fundus  of  Douglas'  cul-de-sac,  from  -within  outward, 
then  deeply  into  the  cervix,  to  the  level  of  the  lateral  insertions  of 
the  utero-sacral  ligament.     Freund  has  performed  it  once. 

Shortening  of  the  round  ligaments  hy  intra-peritoneeal  plicature. — 
G.  Wylie,  first,  then  E.  Bode,  of  Dresden,  proposed  this  method. 
Bode  opens  the  abdomen,  reduces  the  deviation,  passes  a  needle 
thi-eaded  with  aseptic  silk  thi-ough  the  whole  thickness  of  the  round 
ligament,  ties  it,  and  finally  passes  it  on  though  the  corresponding 
uterine  eornua  at  the  insertion  of  the  ligament.  He  then  ties  the 
thread  to  the  extremity  of  the  preceding  knot  and  thus  shortens  the 
ligament  to  an  extent  varying  with  the  distance  of  the  two  knots. 
Wylie's  method  is  analogous.  He  folds  and  sutm-es  the  round 
ligaments,  but  at  its  middle  portion  and  at  some  distance  from  the 
uterus.     He  scrapes  the  peritonaeum  on  the  surfaces  of  the  hgament 


Posterior  Displacements.  297 

which  fold  together.  Polk  unites  the  round  ligaments  in  an  X 
above  the  bladder.  Giuseppe  Euggi,  of  Bologna,  has  also  devised 
a  very  complex  method  of  shortening  the  round  ligament  by 
laparotomy. 

Abdominal  hysterorrhaphy  without  laparotomy  has  been  practiced 
by  a  few.  Kaltenbach  has  operated  by  tliis  method  five  times.  He 
uses  silver  wire  to  fix  the  uterus  to  the  periosteum  of  the  symphysis 
pubis.  Howard  Kelly  has  in  three  cases  sutured  the  uterus  to  the 
abdomen  by  passing  two  or  three  sutures  of  silk-worm  gut  or  of 
silver  wire  through  the  fundus  of  the  organ.  The  sutures  are  fixed 
by  a  lead  shot  crushed  on  them.  Koux  furnishes  an  example  of  the 
dangers  of  this  blind  operation.  In  one  case,  at  the  moment  of 
passing  the  needle,  he  felt  some  niisgi^dngs,  divided  the  abdominal 
wall  and  found  that  if  he  had  persisted  a  loop  of  the  intestine  would 
have  been  entered. 

Vaginal  hysterectomy  has  been  practiced  by  several  surgeons  to 
relieve  the  symptoms  due  to  very  painful  and  obstinate  retroversion. 
Such  an  operation  would  be  legitimate  only  after  the  vain  trial  of 
less  radical  measures  and  in  particular  abdominal  hysterorrhaphy. 

Choice  of  the  operation  for  retroflexion. — The  first  indication  in 
every  painful  retroflexion,  is  to  carefully  seek  the  seat  of  the  inflam- 
matory complication  of  the  deviation  and  the  greater  or  less  mobility 
of  the  organ.  Is  the  uterus  easily  replaced?  If  so  it  is  probable 
that  there  only  exists,  in  addition  to  the  deviation,  a  certain  degree 
of  concomitant  metritis.  If  local  examination,  by  bimanual  pal- 
pation, confirms  tliis  diagnosis,  the  indication  is  first  for  treatment 
of  the  catarrhal  metritis  or  of  the  painful  chronic  metritis.  Cu- 
retting is  necessary,  and  in  the  majority  of  cases  amputation  of 
the  cervix  will  be  indicated.  I  have  observed  in  several  cases  that 
infravaginal  amputation  of  the  cervix  has  been  followed  by  spon- 
taneous replacement  of  the  uterus,  due  without  doubt  to  the 
involution  which  succeeds.  The  uterus  being  reducible,  is  there  any 
notable  lesion  of  the  appendages?  Here  again  the  same  plan 
should  be  provisionally  followed  and  an  attempt  made  to  cure  in 
this  way.  Finally,  a  pessary  may  be  applied  or  the  uterus  may  be 
replaced  by  Alexander's  operation.  It  is  only  when,  at  the  end  of 
some  months  the  deviation  recurs  and  the  pains  persist,  that 
laparotomy  will  be  authorized. 

There  is  also  a  class  of  cases  in  which  shortening  of  the  round 
ligament  for  mobile  retrodeviation  is  an  essential  operation.  This 
is  especially  observed  in  women  of  delicate  constitution  and  nervous 
temperament  in  the  higher  classes  of  society.  It  pertains  to  cases 
in  which  the  deviation  is  the  chief  lesion,  the  inflammation  being  of 
small  extent.  In  this  deviation,  easily  reducible,  it  is  the  excessive 
mobility  of  the  uterus  which  appears  to  be  the  cause  of  the  symp- 
toms, rather  than  the  abnormal  position.     In  fact  the  uterus  may 


298  Posterior  T>is]ilacements. 

sometimes  be  seen  to  take  another  malposition  immediately  after 
reduction;  there  is  marked  relaxation.  Among  such  patients  the 
application  of  a  pessary  immediately  after  replacement  will  be  of 
great  sei-^'ice.  However,  Alexander's  operation  is  better,  as  it  finds 
here  one  of  its  most  rational  applications.  The  patient  should  also 
be  advised  to  wear  a  belt  to  immoliDize  the  abdominal  waDs. 

There  remain  the  adherent  retroflexions.  Here  again  the  diag- 
nosis of  the  complication  is  of  importance.  I  am  not  far  from 
admitting  with  Wylie,  that  nine  times  out  of  ten  in  the  adherent 
retroflexions,  salpingitis  coexists.  I  beUeve  it  is  dangerous  to  make 
repeated  attempts  at  replacement,  either  with  the  finger  or  with  the 
sound  or  repositors.  If  after  the  trial  of  a  moderate  attempt  at 
reduction  under  chloroform,  reposition  can  not  be  accomplished, 
abandon  it.  If  metritis  is  especially  marked,  curetting  and  ampu- 
tation of  the  cervix  may  be  attempted,  in  the  hope  that  the  pain 
will  disappear  with  the  cure  of  the  inflammatory  state.  If  the  me- 
tritis is  but  slightly  pronounced  and  an  old  or  persistent  lesion  of 
the  appendages  is  manifest  laparotomy  may  be  performed.  This 
should  still  be  done  if,  in  the  absence  of  a  manifest  lesion  of  the 
appendages,  there  persist  pains  associated  with  a  deviation,  against 
which  shortening  the  round  ligaments  can  be  of  no  avail. 

With  regard  to  this  laparotomy,  which  is  always  to  a  certain 
degree  explorative,  the  diseased  organs  should  be  removed.  After 
bilateral  castration  and  the  destruction  of  adhesions  the  utenis  is 
frequently  seen  to  become  spontaneously  replaced.  Hysterorraphy 
might  then  be  dispensed  with,  but  as  there  is  always  danger  that 
the  uterus  may  fall  back,  it  is  better  to  sv;tiu'e  this  organ  to  the 
abdominal  walls. 

Finally,  there  are  complex  cases  in  w-hieh  the  retroversion  is 
comcident  with  a  certain  degi'ee  of  general  weakening  of  the  jielnc 
floor  and  of  the  attachments  of  the  uteras.  In  such  women,  com- 
monly multiparfe,  it  appears  that  the  retroflexion  is  the  first  stage 
of  a  prolapsus,  announced  by  the  relaxation  of  the  ^"agina  and  the 
gaping  of  the  ^•ulva.  It  is  then  necessary  to  attack  all  the  morbid 
elements  successively  by  combined  operations — ^the  metritis,  by  the 
curette  and  amputation  of  the  cervix ;  the  weakness  of  the  perin;-eum, 
by  colpoperineorrhaphy ;  the  uterine  deviation,  by  shortening  of 
the  round  ligaments  if  the  organ  is  mobile,  and  by  abdominal 
hysterorrhaphy,  if  the  organ  is  adherent.  Plastic  operations  on 
the  vaguia  and  perinreum  should  only  lie  made  after  hanng  fixed 
the  uterus,  in  order  to  judge  correctly  the  necessary  amount  of 
freshening. 


Prolapsus  of  the  Genital  Onians.  299 


CHAPTER  XIX. 


PROLAPSUS  OF  THE  GENITAL  ORGANS. 

I  unite  under  one  head  prolapsus  of  the  uterus,  that  of  the  interior 
wall  of  the  vagina,  including  the  bladder  (cystocele),  and  that  of  the 
posterior  wall,  which  usually  follows  the  rectum  (rectocele).  These 
various  displacements,  which  have  been  artificially  separated,  are 
closely  connected.  If  they  exist  alone,  it  is  exceptional.  Finally, 
the  etiology  and  the  treatment  associate  these  lesions  and  give  them 
a  true  clinical  unity.  The  hypertrophy  and  the  elongation  of  the 
cervix  must  also  be  included  in  the  anatomical  and  symptomatic 
picture. 

Etiology. — Hart  has  judiciously  compared  these  displacements  to 
those  of  hernias  in  general.  But  there  is  the  difference  that  in  the 
ordinary  hernias  the  organs  pushed  outward  by  intra-abdominal 
pressure  (intestine,  omentum)  are  essentially  mobile,  while  here  we 
have  fixed  organs  that  forcibly  preserve  stable  points  at  their 
attachments  and  thereby  undergo  deformity.  Thus  there  is,  in 
particular,  the  distmguishing  feature  of  hypertrophy  of  the  cervix. 
However,  we  can,  as  in  hernias,  distinguish  in  genital  prolapsus  dis- 
placements by  force  and  displacements  from  weakness.  The  first 
are  produced  in  consequence  of  a  violent  effort,  either  at  once,  or 
when  a  predisposing  cause  has  prepared  the  way.  A  fall  on  the 
buttocks,  an  attack  of  epilepsy  and  violent  paroxysms  of  cough  have 
produced  what  some  authors  call  acute  prolapsus,  even  in  virgins, 
more  frequently  where  one  or  several  parturitions  have  weakened 
the  uterhie  supports.  The  same  fact  has  been  observed  during 
pregnancy  in  like  circumstances.  The  great  changes  in  the  attach- 
ments of  the  gravid  uterus  considerably  favor  prolapsus.  All  the 
ligaments  are  more  voluminous,  but  also  softened.  Intra-abdominal 
pressure  is  augmented  and  acts  more  energetically  on  the  weak 
points  of  the  pelvic  floor,  where  the  vaginal  opening  forms  a  line  of 
cleavage,  always  ready  to  yield  to  efforts. 

Laceration  of  the  periufeum  is  numbered  among  the  predisposing 
causes.  It  permits  a  gaping  state  of  the  vulva,  allowing  air  to 
enter  the  vagina  and  separate  its  walls,  diminishing  thus  the 
resistance  of  the  pelvic  floor.  It  has  even  been  claimed  that  the 
transversus  perinsei  and  the  levator  ani  muscles  may  undergo  a 
subcutaneous  rupture,  or  late  paralysis,  after  puerperal  traumatism 
without  any  apparent  lesion  of  the  skin.  Finally,  the  laxity  of  the 
perinieum,  which  has  been  distended  by  the  ascension  of  the  gravid 


300 


Prolapsus  of  the  Genital  Organs. 


viterus,  enters,  mthout  doubt,  into  the  predisposition  to  prolapsus. 
Must  we  admit  a  congenital  hereditary  predisposition  or  simply  a 
particular  individual  tendency,  resulting  from  the  weakness  of  the 
fixations  of  the  genital  apparatus?  The  latter,  at  least,  is  more 
probable  and  explains  how  efforts,  which  remain  without  effect  in 
the  majority  of  women,  act  in  some  others  to  cause  prolapsus. 


Fig.  164. — Genital  prolapsus.  Prolapse  of  the  anterior  wall  of  the  vagina ;  slight 
cystocele ;  persistence  of  the  posterior  vaginal  cul-de-sac ;  hypertrophy  of  the  middle 
portion  of  the  cervix. 

PatJiological  anatomy. — Certain  classes  must  be  distinguished : 
1.  Prolapsus  of  the  vagina  alone  {cystocele  and  rectocele). — In  the 
great  majority  of  cases  the  fallmg  of  the  vagina  precedes  the  pro- 
lapsus of  the  uterus  and  causes  it,  at  the  end  of  some  time,  as  a 
secondary  phenomenon,  but  it  may  long  remain  uncomplicated. 
The  anterior  wall  of  the  vagina  is  the  part  that  descends  most  easily. 
There  is  commonly  observed  among  women  who  have  borne  many 
children  a  very  slight  degree  of  cystocele,  when  the  bladder  is  full, 
without  constituting  a  true  pathological  condition.  The  anterior 
vaginal  wall  simply  projects  over  the  posterior  and  there  is  no 
serious  consequence  if  the  permieum  has  preserved  a  sufficient 
tonicity.  In  the  opposite  class  of  cases,  however,  a  hernia  of  the 
bladder  has  a  tendency  to  become  pronounced  at  the  ^iilva,  for  this 
organ  is  closely  connected  with  the  vagina  by  its  posterior  surface. 
The  hernia  of  the  bladder  is  occasionally  more  apparent  than  real, 
on  account  of  a  considerable  thickening  of  the  vaginal  wall  covering 
it  (Figs.  164,  165).  It  is  not  long  before  the  posterior  vaginal  wall 
follows  tliis  movement  of  descent.  The  dilated  rectal  ampulla  is 
insinuated  in  the  vaginal  fold,  but  the  laxity  of  the  connections 
between  the  intestine  and  the  posterior  vaginal  wall  prevents  rectal 
prolapsus  at  once,  so  that  rectocele  is  less  frequent  than  cystocele. 
When  these  exist,  the  finger  introduced  into  the  rectum  may  be 


Prolapsus  of  the  Genital  Organs. 


301 


recurved  into  the  posterior  part  of  the  tumor,  which  projects  from 
the  vulva,  while  the  catheter  may  be  passed  into  the  anterior 
segment.  There  is  then  a  bilobed  projection,  usually  unequally 
developed,  which  becomes  more  pronounced  and  more  tense  under 
muscular  efforts,  its  surface  still  presenting  at  first  the  folds  and 
the  color  of  the  vagina.  But  contact  with  the  air  and  frictipn 
quickly  modifies  this  surface  and  it  becomes  thickened,  hard  and 
sometimes  ulcerated. 


Fig.  165.— Genital  prolapsus.  A.  Descent  of  the  anterior  wall  of  the  vagina,  with 
cystocele  and  hypertrophic  elongation  of  the  cervix;  conservation  of  the  posterior 
vaginal  cul-de-sac  (Schroeder).  B.  Complete  prolapse  of  the  vagina,  with  cystocele 
and  without  rectocele.  Hypertrophic  elongation  of  the  supravaginal  portion  of  the 
cervix;   inversion  of  the  posterior  cul-de-sac  of  the  vagina. 

If  the  bladder  or  the  rectum  have  not  been  drawn  down  by  the 
walls  of  the  vagina,  the  peritonsum  may  come  down  in  front  or 
behind,  dipping  in  superabundant  folds  mto  Douglas'  or  the  vesico- 
uterine culs-de-sac.  This  supposes  a  very  great  fixity  of  the 
uterus  and  an  extreme  flaccidity  of  the  serous  membrane,  or  again, 
according  to  Freund,  the  persistence  of  a  foetal  state,  as  in  the 
foftus  the  peritonseal  fold  descends  much  lower.  It  is  then  possible 
that  the  small  intestine  may  be  insinuated,  in  front  or  behind, 
depressing  the  vaginal  walls  and  forming  a  vaginal  enterocele. 
These  lesions  should  really  be  classed  among  the  very  rare  varieties 
of  vaginal  prolapsus.  There  have  been  very  few  cases  pubKshed  of 
vaginal  prolapsus  with  anterior  enterocele,  and  it  is  very  exceptional 
that  vaginal  prolapsus  with  posterior  enterocele  is  observed. 

2.  Simultaneous  vaginal  and  uterine  prolapsus,  with  secondary  hypertro- 
phic elongation  of  the  supravaginal  portion  of  the  cervix. — The  traction 
exercised  by  the  prolapsed  vagina  on  its  attachments  to  the  cervix 
uteri  soon  act  upon  this  organ.  These  attachments  are  loosened  by 
degrees  and  glide  downward  so  that  the  mucosa  of  the  cervix  disap- 
pears by  theeffacement  of  the  culs-de-sac.   From  constant  dragging 


30-2 


Pridapsus  of  the  Genitul  (Jrtjans. 


of  the  vagina  and  because  the  litems  is  still  fixed  above,  the  cervix, 
which  has  become  wholly  supravaginal,  undergoes  a  progi'essive 
elongation.  Sometimes  there  is  simple  elongation  without  hypeitro- 
phy,  but  more  often  the  passive  congestion  and  the  inflammation, 
which  are  constant  in  the  prolapsed  organs,  cause  an  hj^pertrophic 
thiekenuig  of  the  elongated  cervix.  This  hypei-trophy  is  consecutive, 
secondary,  not  primary.  The  sjTnptom  of  these  processes  is  the 
previous  disappearance  of  the  external  cei-vical  mucosa  absorbed  by 
the  efforts  of  traction.  In  the  center  of  the  tumor,  fonned  by  the 
inverted  vagina,  a  cyhndrieal  column  is  felt  which  is  the  thickened 


Fig.  166. — Genital  prolapsus.  Completedescentof  the  vagina,  with  slight  cystocele; 
obliteration  of  the  posterior  vaginal  cul-de-sac;  hypertrophy  of  the  supravaginal  portion 
of  the  cervix. 

and  elongated  cenix.  Frequently  the  posterior  vaginal  wall  gives 
way  later  and  less  completely  than  the  anterior  wall;  the  cavity  of 
the  vagina  still  exists  posteriorly.  However,  the  posterior  siu-face 
of  the  cervix  has  also  participated  in  the  hypertrophy,  and  this  can 
be  appreciated  by  the  finger  introduced  into  the  persisting  posterior 
cul-de-sac  (Figs.  IG-i  and  165).  This  curious  disposition,  which  is 
very  simply  explained  by  the  preceding  consideration,  has  given 
rise  to  a  much  more  complicated  interpretation  by  Schroeder.  He 
attributes  it  to  the  primary  hypertrophy  of  the  median  segment  of 
the  cervix,  subvaginal  or  free  behind,  supravaginal  in  front  (Fig. 
169,  b  b). 

3.  Prolapsus  of  the  vagina  and  of  the  uterus,  resultinij  from  the  pri- 
mari)  hiipertrojihic  elongation  of  the  sujjraiaginal  jMiiion  of  the  eenix. — 
Among  ^■irgins,  whose  perineum  and  vagina  are  perfectly  resistant 
and  ^^'ithout  prolapse  of  the  body  of  the  uterus,  there  has  been 
observed  an  inversion  of  the  superior  portion  of  the  vagina  coexist- 
ing \\itli  an  hypertrophy  of  the  cer^"ix  often  pertaining  to  both  the 
subvaginal  portion  and  the  deeper  or  the  supravaginal  part.  We 
are  then  forced  to  admit  that  it  is  the  initial  eloniration  of  the  cervix 


Prolapsus  of  the  Genital  Organs 


303 


/^' 


"-."•^^M^ 


^***^v 


^IS^'J 


Fig.  l67.~Prolapsus  uteri.     Considerable  hypertrophic  elongatio 
of  the  cervix ;  cystocele. 


Fig.  1 68.— Prolapsus  uteri      Hypertrophic  elongation  of  the  cerv  i\  ;  rectocele. 


304 


Prokijjstis  of  the  Genital  Organs. 


which  has  caused  the  pushing  downward  of  the  vaginal  attachments. 
Later  this  may  be  reversed  and  the  vaginal  prolapsus  become  the 
principal  pheuomeuou  and  elongate  the  cernx  iu  its  turn.  I  believe 
that  gi-eat  value  should  be  attached  to  the  complete  preseiTatiou  of 
the  mucosa  of  the  cervix.  It  is  a  certain  evidence  of  the  absence 
of  traction  at  this  point  by  the  vaginal  insertions. 


Fig.  169. — Division  of  the  cervix  into  three  parts  (Schroder).  P,  peritonseum ;  V, 
bladder;  a,  subvaginal  portion;  b,  median  portion  (subvaginal  behind,  supravaginal 
in  front) ;  c,  supravaginal  portion. 


Fig.  170. — Conoidal  amputation  of  the  cervix  (Huguier's  method).     Natural  size 


Role  of  hypertrophy  of  the  cervix  in  genital  prolapsus. — Huguier 
estabhshed  the  extreme  fi-equence  of  supravagmal  hyijertrophic 
elongation  of  the  cervix  iu  genital  prolapsus.  This  hjiJertrophy,  it 
is  true,  contrary  to  his  opinion,  is  not  always  primary ;  it  is  more 
frequently  secondary,  due  to  the  traction  of  the  prolapsed  vagina, 
and  the  hypertrophy  itself  is  only  consecutive  to  a  stasis  of  blood 
favoring  the  production  of  a  parenchymatous  cerm-al  metritis.  But 
the  fact  remains  that  it  was  unknown  until  Huguier  brought  it 
forward,  aud  advised  amputation  of  the  cervix  as  the  treatment 
(Fig.  170) ,  an  operation  which  still  remains  an  important  factor  iu 
the  relief  of  the  majority  of  cases.  What  is  the  nature  of  the 
hypertrophy  of  the  cervix?  "\Mien  it  succeeds  to  the  continued 
traction  of  the  prolapsed  vagina  and  to  the  consequent  elongation 
we  cannot  refuse  to  see  in  it  an  inflammatory  process.  But,  when 
the  hypertrophy  is  primary,  is  it  the  result  of  a  congenital  predis- 
position to  malformation,  a  predisposition  which  only  manifests  its 


Prolapsus  of  the  Genital  Organs.  305 

effect  at  the  time  of  complete  development  of  the  organ  under  the 
influence  of  puberty  or  of  the  supernutrition  of  pregnancy  ?  Is  it 
the  index,  even  then,  of  a  localized  parenchymatous  metritis  of  the 
cervix?  It  is  possible  that  both  these  factors  may  act  in  turn  or 
simultaneously.  Histological  examination  has  not  given  very  in- 
structive results  on  this  point.  Sufficient  distinction  has  not  been 
made  between  sections  from  a  secondary  hypertrophy  and  those  in 
which  the  hypertrophy  was  the  primary  condition.  Inflammatoi-y 
lesions  may  often  be  secondary  and  not  primary,  for  every  pro- 
lapsed uterus  is  almost  surely  destined  to  become  affected  by 
catarrhal  endometritis. 


Fig.  171. — Prolapse  of  the  primitive  uterus,  without  hypertrophy 
of  the  cervix,  consecutive  to  a  retroversion. 


Fig.  172. — Prolapsus  uteri,  vifith  anteflexion ;  the  uterus  has  lost  its 
connections  with  the  rectum  and  bladder. 

4.  Procidentia  of  the  uterus  and  of  the  vagina  luithout  hijjjertrophy 
of  the  cemx. — There  is   frequently  observed   a   slight   degree   of 


306  Prolapsm  of  the.  Genital  Onjans. 

prolapsus  which  renders  the  cendx  more  accessible  to  the  finger  by 
augmenting  the  depth  of  the  vaginal  culs-de-sac.  But  complete, 
sudden  prolapsus  of  the  uterus  is  nire ;  the  force  of  the  resistance 
to  be  overcome  is  considerable.  These  are  true  forced  hernia.; 
demanding  a  violent  eifort.  It  is  then  the  uterus  generally  which 
drags  down  the  vagina  after  it.  In  order  that  an  eifort  may  exert 
sufficient  effect  on  the  uterus  to  displace  it  toward  the  vulva,  it  is 
almost  indispensable  that  the  organ  should  be  already  in  retro- 
version (Fig.  171).  When  the  uterus  projects  thi-ough  the  \u\\&  it 
may,  in  the  hernial  sac  that  contains  it,  imdergo  deviations  on  its 
axis  and  be  placed  in  antedexion  or  in  retroflexion  (Figs.  172  and 
173).     Finally  inversion  may  be  combined  with  the  prolapsus. 


Fig.  173. — Prolapsus  uteri,  with  retroflexion;  rectocele. 

The  relations  of  the  contiguous  organs  vary  according  to  the 
varieties  and  the  degrees.  In  a  general  way,  the  more  the  cervix 
is  hypertrophied,  the  more  the  peritouseal  folds  are  removed  from 
the  uterine  orifice  (Fig.  171).'  "When  there  exists  a  pronounced 
degree  of  rectocele  (Fig.  173),  fecal  masses  may  accumulate  and 
harden  in  the  cul-de-sac,  which  depresses  the  vagina.  Cystocele 
soon  gives  the  bladder  a  bilobed  form,  with  an  inferior  pocket, 
situated  below  the  internal  orifice  of  the  m-ethra,  that  permit-, 
stagnation  of  urine  (Figs.  16-5  and  171).  There  is,  then,  frequent 
dilatation  of  the  bladder,  and  also  of  the  ureters,  the  renal  pelvis 
and  the  calices  in  consequence  of  the  dragguig  and  the  compression 
of  the  terminal  part  of  the  \ireters.  The  presence  of  calcuK  in  the 
cystocele  has  been  noted,  but  these  observations  are  not  so  numer- 
ous as  might  be  supposed  n  priori.  The  thickening  of  the  vaginal 
mucosa  must  be  noted.  It  takes  on  the  consistency  of  the  skin  or 
of  leather,  has  a  whitish  or  violet  aspect,  and  there  is  sometimes 
oedema  of  the  prolapsed  parts,  ulceration  or  ectropion  of  the  os 


Prohpsus  of  the  Genital  Organs.  807 

uteri  or  abrasion  and  ulcers  due  to  friction  on  the  surface  of  the 
tumor.  In  the  great  majority  of  eases  the  prolapsed  uterus  is 
attacked  by  metritis.     Chi-onie  salpingitis  is  also  quite  frequent. 

Symjjtoms. — Acute  prolapsus,  or  that  produced  suddenly  by  a 
"violent  effort,  is  rare,  but  has  been  observed.  Then,  immediately 
after  the  traumatism  or  violence  which  is  the  cause,  there  is  seen 
to  project  from  the  vulva  a  tumor  consisting  either  of  the  anterior 
wall  of  the  vagina  alone,  or  also  of  the  uterus  itself.  An  intense  pain 
and  sometimes  syncope  and  peritonitis  accompany  this  symptom. 

But  usually  the  prolapsus  is  produced  progressively  and  only  gives 
rise  to  some  vague  and  indefinite  functional  symptoms :  vreight  on 
the  perinaeum,  dragging  from  the  back  and  lower  abdomen,  fatigue 
dm-ing  walking,  accompany  the  other  common  symptoms  of  metritis. 
To  these  there  are  soon  added  disturbances  of  micturition,  dysuria, 
incontinence,  retention,  with  or  without  cystitis.  When  the  cysto- 
cele  is  very  pronounced,  the  patient  aids  herself  in  urination  by 
pressing  up  the  hernia. 

Menstniation  presents  nothing  peculiar.  Abortion  may  follow, 
but  the  uterus  may  also  develop  by  rising  gradually  into  the 
abdomen,  causing  momentary  disappearance  of  the  phenomena  of 
prolapsus.  It  is  very  impoi"tant  to  note  here  that  the  symptoms 
are  not  in  propoi-tion  to  the  degi'ee  of  prolapsus.  Some  women 
complain  but  little,  even  with  a  uterus  down  between  their  thighs, 
while,  on  the  other  hand,  there  are  patients  with  only  a  shght 
degi-ee  of  prolapsus  that  have  severe  pain  during  walking.  In  the 
fii'st  state  it  appears  that  a  new  and  definite  uterine  fixation  has 
taken  place,  permitting  tolerance  of  a  considerable  lesion,  while  in 
the  second  case  this  compensation  is  not  effected.  The  unstable 
condition  of  the  utenis  then  gives  rise  to  incessant  dragging  and  to 
nervous  reflexes. 

The  physical  signs  are  characteristic.  T^Tien  the  prolapsus  is  in  its 
initial  period,  the  vaginal  miicous  membrane,  although  flabby,  can 
only  be  pushed  back  with  some  effort.  On  placing  the  woman  in  the 
dorso-sacral  position,  and  asking  her  to  bear  down,  the  anterior  wall 
will  be  seen  to  push  out  by  a  movement  of  rotation;  or  if  the 
development  is  gi-eater,  a  soft  tumor  will  project  and  return  as 
soon  as  the  effort  ceases.  It  is  important  to  remember  that  the 
anterior  and  posterior  vaginal  walls  are  nonnaUy  relaxed  and 
applied  against  each  other  in  such  a  way  that  the  section  of  the 
canal  in  a  state  of  repose  resembles  a  letter  H.  Prolapse  of  the 
vagina  in  the  form  of  a  cylinder,  then,  should  not  be  expected  as  in 
the  case  of  the  rectmn.  The  anterior  and  the  posterior  walls  alone 
are  prolapsed,  isolated  or  simultaneously  gliding  one  over  the  other, 
or  in  juxtaposition.  The  first  degree  of  cystocele,  of  intermittent 
appearance,  so  to  speak,  gives  place  to  a  permanent  condition. 
Then,  later,  beliind  the  vaginal  tumor  appears  the  os  uteri,  from 


308  Prolapsus  of  the  Genital  Organs. 

which  oozes  the  mucus  of  cervical  catarrh.  If  the  posterior  wall  of 
the  vagina  is  also  di-agged  dowTi,  this  opening  is  found  in  the  center 
and  at  the  summit  of  a  tumor  which  separates  the  labia.  The 
surface  is  dry,  rugous,  hardened  by  exposure  to  the  air,  and  some- 
times presents,  besides  ulcerations  about  the  os  uteri,  losses  of 
substance  due  to  fiiction  and  to  want  of  cleanliness.  The  base  of 
the  tumor  is  surrounded  by  a  more  or  less  deep  groove,  especially 
at  the  fourchette.  It  may  be  of  variable  size,  from  that  of  an  egg 
to  that  of  two  fists  (Figs.  167,  168). 

Palpation  gives  different  sensations  according  as  the  uterus  is  or 
is  not  included  in  the  prolapsus.  All  that  belongs  to  the  vaginal 
protnision  is  flabby.  The  tension  and  the  elasticity  of  the  cystocele 
increase  with  the  repletion  of  the  bladder.  If  enterocele  exists,  as 
in  rare  cases,  borborygmus  may  be  perceived.  In  cases  where  there 
is  prolapsus  uteri  without  cervical  hypertrophy,  even  the  body  of 
the  organ  may  be  palpated  in  the  mterior  of  the  tumor  (Figs.  171, 
172,  1731.  But  in  the  typical  cases  that  I  have  deseiibed  of  pro- 
lapsus with  consecutive,  or  with  primary  hypertrophy  of  the  cervix, 
tliis  segment  alone  exists  in  the  center  of  the  tumor  (Figs.  164,  165, 
166).  It  foruls  the  axis,  more  or  less  thick  and  rigid  according  to 
the  case,  sometimes  giving  to  the  hand  which  palpates  the  sen- 
sation of  a  cord,  sometimes  that  of  an  elastic  cylinder.  By  bimanual 
palpation  it  is  found  to  be  continuous  with  the  body  of  the  uterus 
that  remains  behind  the  pubes.  The  use  of  the  sound  gives  a 
pathognomonic  symptom  in  elongation  of  the  cervix ;  it  sinks  to  a 
gi-eat  depth,  ten  to  twenty  centimetres.  It  must  be  remembered, 
however,  that  the  cervical  canal  may  be  obhterated  in  old  women. 

The  reducibility  of  the  tumor  is  complete  where  the  uterus  does 
not  take  part  in  the  prolapsus.  This  may  also  be  possible  in  case 
the  uterus  is  prolapsed,  but  then  it  can  only  be  maintained  with 
difficulty.  Finally,  a  permanent  reduction  is  almost  always  impos- 
sible, and  in  the  case  of  hypertrophy  of  the  cer\-ix  replacement  can 
only  be  made  by  the  use  of  a  violence  that  is  dangerous.  The 
exact  position  of  the  bladder  wdU  be  appreciated  with  a  male  sound. 

Progress,  Prognosis. — The  progi-ess  of  the  affection  is  essentially 
chronic,  and,  left  to  itself,  terminates  in  a  more  and  more  complete 
prolapsus.  There  are  patients  among  whom  this  prolapsus  of  the 
genital  organs  accompanies  other  large  hernias  and  constitvites  a 
pelvic  eventration  as  incurable  as  abdominal  eventration.  Sponta- 
neous cures  after  peritonitis,  by  fixation  of  the  uterus  with  adhesive 
liands,  have  been  spoken  of,  but  they  appear  to  lack  confu-mation. 

Diagnosis. — Bimanual  palpation,  rectal  touch,  the  uterine  sound 
and  vesical  catheterism  w-Hl  permit  us  to  distinguish  the  tumor 
which  projects  from  the  \-ulva,  from  a  polyijus  and  from  an  mversion 
of  the  utems.  The  difficult  point  of  diagnosis  lies  in  the  precise 
determination  of  the  prolapsed  parts  and  of  the  modifications  of 


Prolapsus  of  the  Genital  Organs.  309 

place,  form  and  volume  that  they  have  undergone.  The  male  sound 
gives  the  hmits  of  the  bladder ;  the  finger  in  the  rectum  follows  its 
dupHcation  forward ;  the  palpation  of  a  rigid  axis  in  the  middle 
of  the  tumor  and  the  determination  of  the  depth  of  the  uterine 
cavity  with  a  somid  will  reveal  the  portion  belonging  to  an  hypertro- 
phied  cervix.  The  state  of  the  peritonseal  culs-de-sac  can  only  be 
appreciated  when  there  is  present  one  of  the  rare  cases  of  enterocele. 
With  an  hypertrophied  cervix  the  peritonaeum  is  distant  from  the 
vagina  and,  on  the  contrary,  in  simple  prolapsus,  without  cervical 
elongation,  the  peritoneum  is  quite  near. 

An  interesting  variety  of  vaginal  prolapsus,  which  can  almost  be 
considered  as  a  special  variety  of  cystocele,  is  m-ethi-ocele.  The  . 
tumor  is  formed  by  the  dilatation  of  the  iirethi'a  or  by  a  cavity  in 
communication  with  this  canal,  the  bladder  remaining  perfect. 
This  affection  is  characterized  by  the  presence  at  the  \Tilva  of  a 
tumor  which  generally  does  not  exceed  the  size  of  a  nut,  situated 
immediately  under  the  canal  of  the  uretlii'a  and  seemingly  continu- 
ous with  the  meatus.  It  becomes  more  tuberant  during  straining 
efforts.  It  can  only  be  distinguished  fi-om  cystocele  by  an  attentive 
examination  and  by  noting  that  it  is  well  limited  superiorly  and  is 
not  continuous  with  the  bladder.  The  sound  penetrates  first  into 
the  pocket  of  the  urethrocele,  then  into  the  bladder  and  this  by 
following  a  longer  passage  along  the  inferior  wall  of  the  urethi-a, 
Avhich  is  pushed  downward,  than  along  the  superior  wall  which 
remains  rectilinear.  The  urethro-vaginal  septum  is  sometimes  very 
tliick,  sometimes,  on  the  contrary,  very  thin.  By  continuing  to 
dilate,  may  not  the  urethrocele  become  transformed  into  cystocele '? 
This  is  doubtful. 

Treatment. — The  prophylaxis  of  genital  prolapsus  lies  wholly  in 
rational  treatment  during  parturition  and  in  subsequent  hygiene. 
Belts  and  pessaries  give  only  a  precarious  and  often  wholly  illusory 
relief  in  these  cases.  However,  the  abdomen  should  be  sustained 
by  a  well-made  belt,  which  takes  the  weight  of  the  intestines  from 
the  pelvic  organs.  With  regard  to  pessaries  they  can  give  results 
only  if  the  perinasum  preserves  a  certain  tonicity.  A  perinaeal 
pad  is  sometimes  a  useful  adjuvant  to  then-  action.  Breisky  claims 
good  results  from  the  use  of  ovoid  pessaries,  which  find  a  sufficient 
point  of  support  in  the  narrow  vagina  of  aged  women.  Trial  may 
also  be  attempted  of  the  ring  pessary,  Hodge's  pessary,  the  sleigh 
pessary  and  the  ball  pessary.  The  Zwanck- Schilling  wing-pessary 
is  of  httle  value. 

That  all  these  pessaries  may  have  some  degi'ee  of  success,  it  is 
necessary,  I  repeat,  that  the  perinseum  retain  a  certain  tonicity  and 
the  vulva  a  certain  contraction.  They  should  be  prescribed  only  as 
temporary  palliatives,  while  waiting  a  curative  operation.  How- 
ever, if  the  patient  refuses  all  surgical  interference,  or  if  this  does 


RIO 


I'lnlaj^sii-'^  of  the  Genital  Organs. 


not  offer  a  considerable  cliauce  of  success,  as  in  obese  women  with 
eventration,  so  to  speak,  of  the  pelvic  contents,  the  only  resource 
lies  in  the  employment  of  the  pessary  composed  of  a  stem  and  cup 
supported  by  an  abdominal  belt.  Cutter's  cup  pessary  is  much 
used.  The  employment  of  the  pessary  must  be  preceded  by 
reduction  of  the  prolapsed  parts  and  by  treatment  dkected  to  the 
engorgement  of  the  organs.  If  there  is  oedema  or  inflammation, 
the  patient  is  kept  at  rest,  frequent  baths  and  prolonged  warm 
injections  are  given,  glycerine  tampons  are  appHed  and  massage  is 
att-empted.  As  soon  as  the  tissues  have  recovered  some  suppleness, 
we  proceed  to  reduction  in  the  semi-prone,  lateral,  or  in  the  genu- 
pectoral  position.  The  rectum  and  bladder  should  be  emptied  first. 
If  there  are  still  difficulties  in  reduction,  it  is  necessary  to  wait  and 
not  to  use  too  much  force. 


Fig.  174. — Prolapsus  uteri,  amputation  of  the  vaginal  portion  of  the  cer\-ix.     A. 
Before  suture.     B.  After  suture,     a,  bladder;   /•,  Douglas'  cul-de-sac. 

Stirgical  treatment  offers  the  greatest  chances  of  success  and 
presents  but  little  gi-avity.  It  should  then  be  preferred  to  the 
emplojTuent  of  pessaries.  The  different  methods  which  have  been 
employed  can  be  classed  thus:  1.  Construction  of  an  inferior 
support  from  the  vulva,  vagina  or  perinaeum.  2.  Eestoration  of 
the  position  of  the  uterus  by  shortening  the  round  Hgaments.  8. 
Suture  of  the  uterus  to  the  contiguous  parts  (hysterorraphy),  through 
the  vagina  or  by  laparotomy.  4.  Hysterectomy.  Before  studying 
these  different  operations,  amputation  of  the  cervix  should  be  noted 
as  a  preliminary  operation,  destined  to  favor  reduction  of  the 
uterus  when  the  cervix  is  hypertrophied.  The  possibility  of  perfect 
coaptation  of  the  mucous  sui-faces  should  always  be  considei-ed, 
after  the  excision  of  a  conoidal  flap  from  each  lip  (Fig.  174). 
Wounds  of  the  bladder  wiU  be  avoided  by  guiding  the  knife  with  a 
sound  introduced  into  this  organ  and  held  by  an  assistant.  The 
rectum  and  peritonseum  will  not  be  in  danger  if  care  is  taken  to 
always  direct  the  knife  toward  the  part  to  be  removed.  The  removal 
of  a  large  segment  is  not  necessary  to  induce  involution  in  the  rest 
of  the  organ  after  amputation. 


Prolajjsvs  of  the  Genital  Organs..  311 

1.  Construction  of  an  inferior  point  of  supjwrt. — The  procedures 
that  belong  to  tliis  method  are  very  numerous.  I  shall  confine  myself 
to  the  simple  enumeration  of  those  that  have  fallen  into  disuse,  and 
devote  the  necessary  space  to  the  description  of  those  wliich  should 
be  employed.  Among  the  old  methods  are  episiorrhaphy,  or  suture 
of  the  labia  majora  to  narrow  the  vulva,  freshening  and  snture  of 
vulvar  orifice,  infibulation,  and  cauterization  of  the  vaginal  wall 
with  various  caustics  or  with  the  actual  cautery — detestable  pro- 
cedures that  some  have  recently  tried  to  revive.  I  will  say  the 
same  of  ligature.  Frank  practices  an  operation  which  aims  at  the 
formation  of  a  vertical  fold  in  the  vagina,  projecting  like  a  living 
tampon.  He  denudes  the  vagina  near  the  posterior  cul-de-sac  and 
places  buried  sutures  of  catgut  to  construct  a  sort  of  buttress.  But 
this  operation  also  constitutes  a  species 'of  colpoperineorrhaphy. 
The  excision  of  a  section  of  the  vaginal  wall,  elytrorrhaphy  or 
colporrhaphy,  was  first  ad"^dsed  by  Marshall  Hall.  His  very  incom- 
plete procediire  is  the  foundation  of  the  perfected  methods  of  to-day. 
Simon  combined  with  this  a  perineorrhaphy,  making  an  excision 
in  the  form  of  a  trapezium.  Anterior  elytrorrhaphy  was  first  per- 
fected by  Sims.  Since  that  time  the  procedures  of  colpoperineor- 
rhaphy have  multiplied.  I  will  only  describe  those  of  Hegar  and 
of  A.  Martin  and  the  perineoplasty  of  Doleris.  I  will  also  describe 
LeFort's  operation,  which  is  exclusively  addressed  to  the  con- 
struction of  a  septum  in  the  vagina. 

Colpoperineorrluqihy  (Hegar's  method). — The  patient  having  been 
purged,  catheterized  and  cleansed  locally,  is  ansesthetized  and 
placed  in  the  dorso-sacral  position.  The  amount  of  tissue  that 
must  be  removed  is  determined  by  seizing  the  posterior  wall  of  the 
vagina  with  the  forceps  and  drawing  it  outward.  In  slight  cases 
it  is  sufficient  to  remove  an  isosceles  triangle  of  six  to  seven  centi- 
metres base  at  the  fourchette  and  of  a  height  of  seven  centimetres  in 
vagina.  When  the  prolapsus  is  more  extensive,  this  is  increased 
by  one  to  two  centimetres.  During  the  operation  very  slow  con- 
tinued irrigation  with  warm  water,  either  slightly  antiseptic  (car- 
bolized,  10-1000),  or  simply  filtered  with  the  addition  of  common 
salt,  6-1000,  will  be  very  ixseful.  One  assistant  gives  chloroform, 
two  others  hold  the  limbs  and  the  forceps,  and  one  other  passes 
the  instruments.  To  uncover  the  field  of  operation,  it  is  unnecessary 
to  employ  retractors ;  while  the  assistant  temporarily  opens  the 
vagina  with  a  Sims'  speculum,  the  surgeon  seizes  the  posterior  wall 
of  the  vagina  with  a  pair  of  bullet  forceps.  These  forceps  are 
placed  in  the  middle  of  the  posterior  wall,  at  seven  to  eight  centi- 
metres from  the  fourchette,  so  that  they  correspond  to  the  apex  of 
the  triangle  that  it  is  intended  to  denude.  The  labia  are  separated 
and  two  other  forceps  are  placed  at  the  limits  of  the  base  of  the 
projected  triangle,  at  six  to  seven  centimetres  from  each  other,  at 


312 


Prolapsus  of  the  Genital  Oniaiis. 


the  extreme  inferior  limit  of  the  vagina.  Two  new  forceps  are  now 
placed  toward  the  middle  of  the  sides  of  the  triangle.  When  all 
these  forceps  are  properly  drawn  ont  hy  the  assistants  the  field  of 
operation  is  sjiread  out  and  tense.  "With  a  very  sharp  convex  knife 
the  operator  traces  the  limits  of  the  triangle,  taking  care  to  give  it 
a  concave  form  at  the  base,  and  slightly  convex  toward  its  interior 
at  the  sides.  To  dissect  this  triangle,  the  point  is  seized  ^vith  the 
forceps  and  it  is  isolated  until  the  instrument  can  be  replaced  by 
the  fingers.  During  this  time  the  detached  mucosa  is  dra\\"n  quite 
tense  to  facilitate  the  dissection.  If  the  recto-vaginal  septum  is  thin 
and  there  is  danger  of  wounding  it,  one  finger  may  be  introduced 
into  the  anus.  For  this  the  rectum,  before  the  operation,  must  be 
perfectly  cleansed  «-ith  boracic  acid  or  salicylic  acid  solutions,  un- 
der the  direction  of  an  assistant.  If  there  are  profusely-bleeding 
vessels,  forceps  may  be  placed  on  them.  The  thickness  of  the  tissue 
to  be  removed  should  comprise  all  the  depth  of  the  mucous  mem- 
brane. The  wound  is  trimmed  with  the  curved  scissors,  taking 
great  care  to  remove  projections  and  islets  of  mucous  membrane. 


/  ^     \   ^ 

Fig.  175. — Colpoperineorrhaphy.     Hegar's  method. 

For  sutures  Hegar  uses  silver  wire  that  he  passes  under  the  whole 
surface  of  the  wound,  and  between  the  deep  sutures  places  super- 
ficial stitches  (Fig.  175").  The  continued  suture,  in  superposed  planes 
which  I  have  described,  appears  to  me  to  be  infinitely  preferable. 


Prolapsus  of  the  Genital  Organs, 


313 


Fig.  176. — Colpoperineorrhaphy.     A.  Martin's  method. 
Continued  suture  in  superposed  rows. 

Colpope7i)ieorrhaphy  or  perineauxesis  (A.  Martin's  method). — Mar- 
tin's especial  aim  in  Ms  procedure  is  to  preserve  the  posterior 
column  of  the  vagina,  which  forms  the  most  resisting  part  of  the 
posterior  wall,  and  which  Freund  was  the  first  to  advise  retaining 
in  all  plastic  operations.  Besides  this,  the  denuded  surface,  while 
being  extended,  is  not  designed  as  a  single  support  but  is  divided ; 
a  more  favorable  condition,  it  seems,  for  exact  suture  and  perfect 
reunion.  The  same  preliminary  precautions  having  been  taken  as 
in  the  preceding  operation,  Martin  seizes,  with  two  forceps,  the 
posterior  wall  of  the  vagina  immediately  below  the  cul-de-sac  and 
draws  the  membrane  very  tense.  The  vaginal  column  then  appears 
as  a  projecting  fold,  along  which,  with  a  knife,  an  incision  is  made 
on  each  side.  Then  two  small  lateral  sections  are  marked  out  and 
dissected,  to  a  finger's  breadth  from  the  fourchette.  At  the  base  of 
the  small  sections,  the  same  as  at  the  summit,  forceps  are  placed 
to  aid  in  keeping  the  field  of  operation  tense.  The  two  small 
wounds  are  sutured  with  a  continued  suture  in  superposed  rows 
(Fig.  176).  The  forceps  are  withdrawn  and  the  first  part  of  the 
operation,  the  double  lateral  elytrorrhaphy,  is  then  completed. 
The  second  part,  or  the  perineauxesis,  remains.  A  transverse 
incision  is  made  a  little  above  the  fourchette,  cutting  the  vaginal 


314 


Prokqisus  of  the  Genital  On/ans. 


columu,  and  carried  above  on  each  side  to  nearly  one-half  the  height 
of  the  vaginal  ring.  From  the  extremity  of  this  incision  another  is 
made  wliieli  opens  at  an  acute  angle,  passing  to  the  base  of  the  labia 
minora  and  joining  the  foot  of  the  vertical  incisions  of  the  elytror- 
rhaphy.  Thus  is  obtained  a  transverse  section  in  the  form  of  a 
crescent  with  its  concavity  upward  (Fig.  177)  which,  when  its 
extremities  are  di-awn,  takes  the  form  of  a  lozenge.  Tliis  section  is 
dissected  up,  and  the  wound  reunited  with  a  continuous  suture  of 
superposed  rows  of  catgut  (Fig.  178). 


Fig.  177.— Colpopcnneorrhaphy;  A.  Martin's  methnd.  Denuded  surface.  I  2, 
incision  along  the  posterior  vaginal  column  ;  3  4,  incision  on  tiie  lateral  wall  of  the 
vagina.  /,  extremity  of  the  denundation  at  the  vulvar  orifice  ;  A  A,  B  B.  aa,  b  b,c 
c,dd,  BaB,  S  S,  V  }',  indicating  the  points  which  should  be  superposed  after  the 
suture. 

Bischoff  has  recommended  a  procedure  which,  like  Martin's 
■method,  preserves  the  vaginal  column  (Fig.  179).  Winckel  dissects 
np  the  inferior  third  of  the  vagina,  from  two  to  thi'ee  centimetres 
above  the  remains  of  the  hymen  to  three  or  four  centimetres  from 
the  uretlu"al  orifice,  and  reunites  this  surface  (Fig.  180). 

Colpopenneorrhciphij  (Doleris'  method). — This  ingenious  combi 
nation  of  Lawson  Tait's  procedure,  of  Schi'oeder's  method  of  detach- 
ment of  the  mucous  membrane  and  of  Emmet's  suture,  will  find 


Prolcqisus  of  the  Genital  Orijans. 


315 


Fig.  178. — Colpoperineorrhaphy.     Martin's  method.     Continued 
suture  in  superposed  rows  (deep  layer). 


Fig.  179. — Colpoperineorrhaphy.     Bischoff' s  method. 


316  Prolapsus  of  the  Genital  Organs. 

its  application  in  cases  where  there  is  no  prolapsus  of  the  uterus,  or 
where  this  is  of  sUght  degi-ee,  but,  the  ^^llva  gaping,  there  is  marked 
tendency  to  vaginal  prolapsus,  ^"ith  or  ^\ithout  incomplete  mpture 
of  the  perinseum.  It  is  an  excellent  means  of  repair  in  an  almost 
fresh  state  of  perineal  laceration.  But  the  weak  point  of  the 
procedm-e,  which  makes  it  of  doubtful  utilitj'  in  marked  uterine 
prolapsus,  is  in  the  diminution  of  the  length  of  the  posterior  vaginal 
waU,  thus  preventing  the  necessary  elevation  of  the  uterus.  It  can 
then  be  combined  with  Alexander's  operation  as  weU  as  with  the 
methods  of  Hegar  and  ilartin.  Finally,  it  does  not  naiTOW  the 
vagina  itself,  but  only  the  vulvar  orifice.  It  is,  in  reality,  a  peri- 
neoplasty, pm-e  and  simple,  for  the  portion  of  the  vagina  that  is 
removed  never  can  be  considerable. 


Fig.  i8o. — Colpoperineorrhophy.     Winckel's  method. 

Doleris  traces,  with  a  knife,  a  deep  curved  incision  at  the  junction 
of  the  skin  and  mucous  membrane.  Forceps  are  placed  at  the  two 
outer  points  to  fix  the  tissues.  The  superior  mucous  Hp,  of  the 
incision,  is  dissected  to  a  small  extent  and  then  uplifted  with  the 
forceps.  The  operator  then  uses  only  the  index  finger  of  the  left 
hand  which,  by  pushing  back  the  tissues,  separates  the  vaginal  fi-om 
the  rectal  wall.  This  separation  is  carried  to  the  point  intended  to 
limit  the  loss  of  substance  which  the  vaginal  wall  undergoes.  This 
wall  is  di'awn  oiitside  the  vulva  and  resected,  while  a  proper  i)ortion 
of  it  is  fitted  to  the  first  incision.  The  coaptation  is  made  with  the 
silk-worm  gut  sutui'es  and  curved  needles.  The  fii'st  sutui-e  is  the 
nearest  the  middle.  The  needle  enters  lateraUy  to  the  left  of  the 
anus  and  passes  deeply  thi-ough  the  tissues,  catching  up  the  vaginal 
flap  near  the  extreme  point  of  its  detachment.  It  may  be  brought 
out  into  the  vaguia,  or  not,  and  finally  follows  an  inverse  route  to 
make  its  exit  on  the  right  s  de  of  the  anus.  This  first  sutm-e  is 
intended  to  bring  the  vaginal  wall  toward  the  vulvar  commissure, 
at  the  same  time  that  it  serves  to  coapt  the  edges  of  the  cutaneous 
poi-tion  of  the  incision.  The  second  and  the  thii-d  sutui-es  are  placed 
in  the  same  way  and  a  httle  exterior  to  the  first.  Then  the  excess 
of  the  vaginal  wall  which  borders  on  the  recoustmcted  fom-chette 
is  excised  and  the  two  Ups,  mucous  and  cutaneous,  of  the  wound, 
are  reunited. 


Prolapsus  of  the  Genital  Organs. 


317 


Fig.  i8i. — Colpoperineoplasty  by  flap-splitting.     Method  of  Doleria. 

Semicircular  incision  from  A  to  B. 
Fig.  182. — Colpoperineoplasty  by  flap-splitting.     A  B  D,  vaginal  flap. 


Fig.  183. — Colpoperineoplasty  by  flap  splitting     The  sutures  are  tied; 
the  flap  A  B  D  is  uplifted,  ready  to  be  resected  on  the  line  A  B. 

Colpoperineorraphy  is  the  fundamental  operation  for  genital  pro- 
lapsus. However,  it  is  necessary  frequently  to  supplement  it  with 
auxiliary  operations,  amputation  of  the  cer\-ix,  and  colporrhaphy  or 
anterior  elytrorrhaphy.     The  first  facilitates  the  replacement  of 


318 


PnilajhsHs  of  f]ie  Genital  Orij<iii>i 


the  litems,  the  second  at-ts  directly  on  the  ijrolapse  of  the  anterior 
wall,  or  eystocele. 


Fig.  184. — Colpoperineoplasly  by  flap- 
splitting.     The  flap  has  been  excised. 


Fig.  185. — Colpoperineoplasly  by  flap- 
splitting.     Sutures  finished. 


Anterior  elytrorrhaphy  was  practiced  hy  Sims  in  the  form  of  a 
horseshoe  Avith  its  summit  directed  toward  the  uretkra.  Emmet 
gave  the  wound  the  form  of  a  mason's  trowel.  Hegar  recommends 
giving  the  denuded  surface  the  shape  of  an  ellipse,  very  lilunt  at  the 
upper  extremity.  Generally  it  is  irseless  to  attempt  to  cut  a 
section  of  any  special  form ;  aU  the  exuberant  portion  of  the  vagina 
must  be  freely  excised.  I  have  found  it  very  convenient  to  form  a 
fold  of  the  mucosa  by  the  use  of  two  or  thi-ee  forceps,  the  highest 
about  two  centimetres  from  the  cervix,  and  the  lowest  at  thi'ee 
centimetres  from  the  orifices  of  the  urethra.  Then  a  pair  of  strong 
and  long  curved  forceps,  or,  if  necessary,  two  pair  (Fig.  186)  are 
placed  on  this  fold.  If  a  strong  traction  is  given  to  the  fold  of 
vaginal  mucous  membrane  there  is  no  danger  to  the  bladder. 
Hegar  places  silver-wire  sutures  below  the  forceps  (or  the  clamp) 
before  excising  the  vaginal  fold.  I  employ  the  continued  suture  in 
superposed  rows.  I  first  excise  the  mucous  fold,  then  I  suture,  as 
has  been  indicated,  after  having  exposed  the  operative  field  in  a 
convenient  manner  by  the  use  of  the  forceps  (Fig.  187). 

Stoltz  has  designed  an  ingenious  means  of  suture  for  anterior 
colporrhaphy.  After  the  denudation,  with  a  suture  armed  with  a 
needle  at  each  end,  he  bastes  the  borders  of  the  wound  at  about  one 
centimetre  fi'om  the  edge  in  such  a  way  that  the  tlu-ead  passes 


Prolapsus  of  the  Genital  Organs. 


319 


around  the  wound  like  the  cord  of  a  tobacco  bag  around  its  mouth. 
The  ends  of  the  thread  have  only  to  be  drawn  on  to  close  the  denuded 
surface.  This  method  was  the  most  expeditious  before  the  use  of 
the  continued  suture  in  superposed  rows,  but  the  latter  should  now 
have  the  preference.  Stoltz  excises  directly  by  dissection,  with  the 
curved  scissors,  the  anterior  vaginal  wall,  previously  depressed  by  a 
sound  placed  in  the  l)ladder. 


Fig.  i86. — Anterior  elytrorrhaphy. 

I.  Le  For^s  method.— Thi?,  author  attempts  the  retention  of  the 
prolapsed  organs  by  uniting  the  opposed  walls  of  the  vagina  after 
having  removed  from  each  one  of  them  a  vertical  strip  of  mucous 
membrane  (Figs.  188  and  189).  Sometimes  the  prolapsed  uterus 
has  acquired  such  a  volume  that  it  is  difficult  of  reduction  at  first. 
To  obtain  this  reduction  by  degrees,  the  patient  is  left  in  bed  eight  to 
fifteen  days.  After  this  time  the  passive  engorgement  has  ceased, 
or  at  least  diminished,  and  the  uterus  is  smaller.  The  place  of 
denudation  should  be  as  near  as  possible  to  the  vulva,  since  it  is  in 
this  portion  of  the  vagina  that  the  walls  tend  to  separate  and 
permit  the  prolapsus.     Usually  at  the  moment  of  operating  the 


320 


Prolapsus  of  the  Genital  Organs. 


surgeon  reduces  the  uterus,  opens  the  vulva,  and  makes  two  trans- 
verse incisions  with  the  knife,  one  on  the  anterior  wall,  the  other 
on  the  posterior  wall  of  the  vagina  at  the  lowest  point  where  these 
two  walls  come  together  (the  uterus  being  replaced).  These  two 
incisions  constitute  the  inferior  limit  of  the  two  portions  to  be 
excised.  The  length  of  the  section,  vertically,  is  from  four  to  five 
centimetres,  the  vaginal  waUs  being  infolded  and  distended  by  the 
prolapsus  uteri  that  is  induced  before  commencing  the  excision. 


Fig.  1S7.— Anterior  elytronhaphy ;  the  flap  has  been  dissected. 


The  width  of  the  denudation  advised  by  Le  Fort,  was  at  first  small, 
one  centimetre  to  one  and  one-half  centimetres.  At  present,  Le 
Fort  makes  it  larger  (two  centimetres).  It  should  not  be  too  large, 
for  beyond  certain  limits  the  attachment  of  the  opposed  surfaces  is 
not  easily  made.  The  denudation  should  be  as  thin  as  possible. 
A  raw  surface  is  all  that  is  necessary.     The  removal  of  too  much 


Prolapsus  of  the  Genital  Organs. 


321 


tissue  endangers  the  contigiious  tissues.  Generally,  he  commences 
by  four  incisions  to  trace  the  limits  of  the  section,  thus  making 
their  dissection  easier.    Le  Fort  ordinarily  uses  silver- wire  sutures. 


Fig.  iS8. — Le  Fort's  procedure.     R,  rectum;   UR,  urethra;  A,  anterior 
denudation ;   B,  posterior  denudation. 

He  has  tried  silk,  but  failed  in  two  operations  in  which  it  was  used. 
The  sutures  pass  clear  to  the  center  of  the  freshened  surface:  The 
first  is  passed  in  the  middle  of  the  raw  surface  nearest  the  uterus. 
Once  the  parts  A  B  are  brought  in  contact  by  the  replacement  of 
the  uterus  only  the  borders  of  the  section  need  be  sutured.  The 
sutures  are  left  in  place  fifteen  days,  sometimes  three  weeks.  Out 
of  forty  cases  of  Le  Fort's  operation,  that  Andre  collected,  there 
were  thirty-five  successful,  and  of  these  thirty-one  were  primary 
successes.  It  is  interestmg  to  note  that  this  operation  obstructs 
neither  coition,  fecundation  nor  confinement.  Delivery  took  place 
normally  in  one  of  Le  Fort's  cases.  Section  of  the  artificial  septum 
with  the  scissors,  permitted  the  passage  of  the  fcetus. 

Management  after  colpoi)erineorrhaiphy — The  care  which  should  be 
given  to  patients  after  the  plastic  operations  intended  to  reinforce 
the  perinseum  and  to  narrow  the  vagina,  is  very  important  for  the 
success  of  union  by  first  intention.  If  this  reunion  is  lacking  to 
any  extent,  the  result  of  the  operation  is  almost  always  compromised, 
although  cases  have  been  cited  where  immediate  secondary  reunion 
of  a  granulating  wound  has  resulted  successfully.  The  line  of  the 
suture  should  be  powdered  with  iodoform  and  covered  with  iodoform 
gauze.  The  use  of  a  sound  in  the  bladder  should  be  proscribed. 
It  is  preferable  to  allow  the  patient  to  urinate  every  two  or  three 
hours,  or  to  catheterize  with  an  aseptic  catheter.  I  believe  it  is 
useful  to  defer  movement  of  the  bowels  until  the'  fourth  day,  and 


322  Prolapsus  of  the  Genital  Onjans. 

then  to  solicit  it  with  au  enema.  The  administration  of  two  opium 
pills,  of  two-hmidredths  centigrammes,  each  day,  will  be  sufficient, 
with  a  reduced  diet  to  avoid  premature  evacuation.  The  patient 
should  not  be  allowed  up  under  a  month. 


Fig.  189' — Le  Fort's  procedure.  A,  denuded  surface  on  the  anterior  wall  of  the 
vagina;  B,  denuded  surface  of  the  posterior  wall;  C  C,  one  thread  of  the  left  side; 
D  D,  thread  of  the  right  side. 

Gravity ;  Immediate  and  secondary  results  ofcolpoperineorrhaphy. — 
The  experience  of  all  gynaecologists  who  have  performed  this 
operation  frequently  affirms  its  benignity  and  its  great  efficiency. 
The  accidents  to  be  feared  are :  Opening  of  the  peritonaeum,  whii-h 
with  a  perfect  antisepsis  presents  no  gravity ;  wound  of  the  rectum, 
which  a  suture  renders  harmless ;  suppuration  and  loosening  of  the 
suture,  that  can  be  avoided  by  earefiiUy  preparing  the  catgut  and 
taking  the  most  minute  precautions  against  infection.  Hegar,  out 
of  four  hundred  operations,  has  seen  two  deaths  from  septicaemia. 
Still  later,  the  results  have  been  even  more  satisfactory ;  for  three 
and  one-half  years  Hegar  has  not  had  a  single  failure  out  of  one 
hundred  and  fifty  operations. 

II.  Alquie- Alexander- Adams'  operation. — I  have  already  described 
the  technique  of  this  procedure  in  the  chapter  on  retroversion. 
Applied  alone  to  the  treatment  of  prolapsus  this  operation  has 
given  in  general  mdifferent  results,  thoiigh  some  have  had  good 
success  with  it.  But  it  is  excellent  in  combination  with  plastic 
operations  on  the  vagina  and  perinaeum,  in  thin  women  with  abdomi- 
nal walls  that  are  not  too  much  relaxed.  It  appears  especially 
suited  to  the  correction  of  the  retroversion  which  accompanies  pro- 
lapsus and  forms  one  of  its  elements. 


Prolapsus  of  the  Genital  Organs.  3'2B 

III.  Gastro-Uysterorraphy. — I  will  refer  also,  for  the  description 
of  the  technique  of  tMs  operation,  to  the  preceding  chapter.  If 
there  is  the  complication  of  an  abdominal  tumor,  fibroid  or  cyst, 
the  fixation  of  the  pedicle  in  the  wound  wiU  be  an  excellent  curative 
measure.  It  is  important  to  note  that  it  is  not  to  the  whole  genital . 
prolapsus  but  only  against  the  uterine  prolapsus  that  hysterorraphy 
applies.  A  cystocele  or  a  rectocele,  unless  accompanied  with 
descent  of  the  uterus,  does  not  justify  this  method  of  fixation. 
Both  in  a  theoretical  and  in  a  practical  point  of  view,  hysterorraphy 
is  sufficient  of  itself  only  in  those  rare  eases  where  the  uterus,  not 
increased  in  size,  is  alone  prolapsed.  In  all  other  cases,  a  supple- 
mentary operation  on  the  cervix,  vagina  or  perinjeum  is  necessary. 
From  this  point  of  view,  then,  hysterorraphy  is  not  superior  to 
Alexander's  operation.  It  is  necessary,  therefore,  to  establish  a 
parallel  between  these  two  operations,  as  much  in  point  of  gravity 
as  of  efficacy. 

It  is  not  necessary  to  dwell  on  the  first  point ;  the  relative  be- 
nignity of  Alexander's  operation  is  evident.  This  consideration 
does  not  solve  the  question,  but  it  should  have  weight  in  deterring 
the  surgeon  from  a  graver  procedure  before  having  tried  the  more 
benign.  There  remains  the  question  of  efficacy.  The  elements  of 
a  judgment  based  on  experience  are  too  defective  to  allow  us  to 
pronounce  definitely  on  gastro- hysterorraphy  against  prolapsus. 
The  operations  are  too  small  in  Inumber  and  of  too  recent  date. 
One  patient  operated  on  by  Olshausen  experienced  a  speedy  return 
of  her  malady.  It  is  true  that  the  sutures  seem  to  have  been  in- 
sufficient in  this  case.  A  second  patient  of  the  same  author,  where 
fixation  was  made  in  the  course  of  an  ovariotomy,  had  been  cured 
a  year  and  a  half  in  1886.  In  a  patient,  operated  on  by  Phillips,  the 
cure  had  been  permanent  for  six  months,  at  the  time  of  publication 
of  the  observation.  Here,  again,  it  was  the  pedicle  of  an  ovary 
that  was  fixed.  Dumoret  has  cited  eight  successes  out  of  eleven 
operations  of  this  kind.  The  three  cases  of  Ferrier  are  of  too  recent 
date  to  admit  of  judgment.  The  proportion  of  two  failures  and 
one  death  cannot  be  neglected  and  scarcely  justifies  the  enthusiasm 
that  this  operation  has  awakened. 

IV.  Vaginal  hysterectomy. — I  believe  abdominal  hysterectomy, 
except  in  ease  of  fibroid,  is  unjustifiable.  With  regard  to  vaginal 
hysterectomy,  although  not  so  grave,  it  is  much  more  so  than  the 
plastic  operations.  It  should  be  reserved  then  as  a  last  resort.  It 
must  be  also  noted  that  the  vaginal  prolapsus  may  persist  after  it 
and  necessitate  a  colpoperineorraphy,  even  if  care  has  been  taken 
to  remove  a  large  section  of  the  vaginal  mucosa. 

Choice  of  operation. — The  therapeutic  indications  for  the  different 
types  of  genital  prolapsus  that  I  have  distinguished  can  be  briefly 
stated  as  follows : 


3'24  Prolapsus  of  tlic  (ienlhil  Organs. 

As  a  temporary  palliative,  pessaries  or  hysterophores,  applied 
after  reduction  of  the  bulk  of  the  prolapsus  by  a  recumbent  position, 
baths,  tampons,  or,  if  necessary,  amputation  of  au  hypertroi^hied 
cervix.  Massage  has  been  advised  lately  for  the  majority  of  uterine 
affections  and  particularly  for  prolapsus.  I  believe  it  will  render 
actual  service,  combined  with  rest  and  baths,  in  diminishing  the 
volume  of  the  prolapsed  parts  and  in  facilitating  reduction.  Brandt 
advises  it  as  follows  :  One  of  the  operators  lifts  up  the  uterus  with 
two  fingers  in  the  vagina,  the  other  pushes  the  hands  down  between 
the  litems  and  the  symi)hysis  and,  slowly  pressing  the  ends  of  his 
fingers  as  deeply  as  possible,  he  elevates  them  and  lowers  them  a 
dozen  times.  A  daily  treatment  for  eight  days  is  sufficient.  It 
will  be  idle  to  expect  a  spontaneous  retention  of  the  organs  thus 
replaced.  Only  a  temporary  relief  will  be  obtained  that  will  not 
obviate  the  necessity  for  a  plastic  operation. 

As  to  the  curative  treatment,  it  is  necessary  to  distinguish  several 
classes  of  cases : 

1.  Simple  prolapsus  of  the  vagina  without  hypertrophy  of  the 
cervix  and  without  descent  of  the  uterus :  Anterior  elytrorraphy 
and  colpoperinaeorraphy  (Hegar's  method)  when  the  vagina  is  much 
stretched;  in  cases  where  the  cystoeele  is  slight,  anterior  elytror- 
raphy, followed  by  colpoperineoplasty  (Doleris'  method)  to  increase 
the  resistance  of  the  perinteum. 

2.  Vaginal  prolapsus  and  uterine  descent,  with  hypertrophic 
elongation  of  the  supravaginal  portion  of  the  cer^'ix :  Biconical 
amputation  of  the  cervix,  anterior  elytrorraphy  and  colpoperineor- 
raphy.  Hegar's  method  is  usuallj'  employed  but  Martin's  method 
is  to  be  preferred  if  the  vagina  is  excessively  large  and  flabby :  a 
gi'eater  surface  can  then  be  removed. 

When  the  body  of  the  uterus  has  descended,  shoi-teuing  the  round 
ligaments  will  foUow  immediately  after  amputation  of  the  cervix, 
before  proceeding  to  plastic  operations  on  the  vagina.  In  cases  in 
which  the  preceding  measures  fail,  gastro-hysterorraphy  will  be 
combined  with  vaginal  operations.  In  complete  and  inveterate 
prolapse  of  the  vagina  and  uterus  where  the  prolapsed  paris,  very 
much  hypertrophic d,  are  reduced  and  mamtained  with  gi-ea  diffi- 
culty, vaginal  hysterectomy  will  be  justified,  with  a  large  excision 
of  the  vagina,  and  later,  a  colpoperineorraphy  to  considerably  nar- 
row the  vulvar  orifice. 

3.  Prolapsus  of  the  uterus  and  vagina  without  hypertrophy  of  the 
cervix.  Shortening  the  round  ligaments,  then  colpoperinfeorraphy 
(Hegar's  or  Martin's  method  according  the  gi-eater  or  less  width  of 
the  vagina)  or  LeFort's  operation.  Finally,  if  there  exist  a  me- 
tiitis  in  any  case  of  prolapsus,  the  treatment  should  always  be 
commenced  by  curetting. 


Inversion  of  the  Uterus. 


325 


CHAPTER  XX. 


INVERSION   OF   THE  UTERUS. 

By  the  term  inversion  of  the  uterus  is  designated  an  invagination 
of  the  organ  on  itself,  in  such  a  manner  that  the  fundus,  depressed 
like  the  finger  of  a  glove,  projects  to  a  greater  or  less  extent,  either 
into  the  uterine  cavity  or  into  the  vagina.  The  fii-st  stages  of  this 
inversion  usually  escape  observation  and  may,  besides,  be  only 
temporary.  The  fiindus  of  the  organ  opens  the  cervix  and  forms  a 
considerable  projection  before  it  attracts  attention.  The  different 
degrees  previously  admitted  and  taught  by  classic  authors  (Fig. 
190)  have  only  a  theoretical  mterest.  The  division  into  complete 
and  incomplete  inversion  is  much  more  important.  Complete  in- 
version, that  where  there  does  not  exist  the  surrounding  projecting 
border  of  the  cervix,  is  so  rare  that  only  doubtful  examples  have 
been  cited.  The  only  useful  division  for  clinical  purposes  is  that 
into  simple  inversion  and  inversion  with  prolapsus. 


Fig.  190. — Inversion  of  the  uterus.  Schematic  iigure  showing  the  three  degrees. 
<2,  inverted  fundus ;  ^,  uterine  cavity;  <:,  vagina;  ij',  superior  border  of  the  depression 
formed  by  the  inverted  fundus. 

Patholoc/y,  ^Etiology. — In  order  that  inversion  of  the  uterus  may 
be  produced,  a  part  of  the  body  must  become  inactive  and  afford  a 
hold  for  the  contractions  of  that  portion  of  the  uterine  muscular 
tissue  situated  below  it.  These  conditions  are  fulfilled  in  two 
different  classes  of  cases,  after  delivery,  or  in  consequence  of  a 
fibroid  pointing  toward  the  cavity.  In  both  these  circumstances 
the  uterus  is  hypertrophied  and  dilated ;  in  both  one  zone  of  its 
surface  is  inactive  and  depressed.  In  the  case  of  parturition,  this 
is  the  region  where  the  placenta  was  implanted,  that  Eokitansky 
has  described  as  a  "paralysis  of  the  placental  zone";  in  the  case 


3'2(j  Iiiivrs'ioit  of  tlic  Uterus. 

of  fibroid,  it  is  the  surface  of  the  implantation  of  the  tumor.  A 
ti"action  from  below  on  the  eorcl,  an  impulsion  from  above,  pro- 
ceeding from  an  exaggerated  effort  of  the  abdominal  waUs,  may,  in 
these  cases,  cause  the  depression  of  the  fundus  of  the  uterus ;  if 
the  rest  of  the  organ  then  contracts,  the  depressed  portion  is,  so  to 
speak,  seized,  and  an  automatic  movement  like  that  of  deglutition 
brings  it  do^Miward  thi-ough  the  cer\ix. 


Fig.  191. — Inversion  of  the  uterus,  with  descent,  without  prolapsus. 

Among  the  most  common  active  causes  should  be  mentioned, 
shortness  of  the  cord,  excessive  tractions  on  the  placenta,  abnormal 
adhesions  of  this  organ  and  its  insertion  in  the  fundus  of  the  uterus, 
deliveiy  in  the  upright  position.  Partial  inversion  is  often  effected 
unkno\^'n  to  the  physician ;  then  the  depression  of  the  fundus  of  the 
uterus  contmues  its  descent  during  the  first  few  days  following 
delivery  and  the  inversion,  which  has  been  going  on  since  the  first 
moment  of  confinement,  becomes  manifest  only  at  the  end  of  some 
days.     Its  appearance  is  sometimes  gradual  and  sometimes  abrupt. 

This  puerperal  origin  is  the  most  fi-equent.  Crosse,  out  of  four 
hundred  cases  of  inversion,  found  three  hundred  and  fifty  consecu- 
tive to  pai'turition  and  fifty  to  polypi.    Fibroids  and  fibro-sarcomata 


Inrersion  of  the  Uterus. 


327 


inserted  into  the  fundus  of  the  uterus,  especially  those,  which  have 
been  the  object  of  attempts  at  traction  may  cause  inversion  even 
among  nulliparous  women.  Inversion  is  a  rare  affection.  Beigel, 
from  statistical  researches,  found  that  it  occurred  only  once  out  of 
190,000  confinements. 


Fig.  192. — Inversion  of  the  uterus  and  prolapsus  caused  by  a  fibroid. 


Pathological  anatomy. — An  important  distinction  is  that  between 
the  recent  puerperal  inversions  and  the  cln-onic  inversions.  The 
condition  of  the  uterus  at  the  time  of  parturition  makes  a  radical 
difference  between  these  two  affections.  In  the  first  there  exists  a 
variety  of  inversion  that  could  be  called  acute,  a  formidable  acci- 
dent which  may  cause  death  by  sudden  and  violent  hsemorrhage.  I 
will  not  dilate  here  on  this  variety,  as  it  is  essentially  obstetrical. 

By  recent  puerperal  inversion  I  designate  the  cases,  where  the 
appearance  of  the  tumor  constitutes  the  principal  phenomenon  to 
which  the  remedy  is  to  be  applied,  where  they  are  presented  to  the 


328  Inversion  of  the  Uterus. 

burgeon  soon  after  accouchement  (a  month  and  a  half  on  the  average), 
and  where  uterine  involution  has  not  terminated.  By  chronic 
inversion  I  designate  cases  of  longer  standing. 


Fig.  193.  —  Inversion  of  the  uterus.  (7,  vagina;  (5,  fundus  of  the  uterus;  c  c, 
superior  border  of  the  inversion ;  c  d,  portion  of  the  cervix  not  inverted ;  f,  cul-de- 
sac;  ^^,  tubes;  ,4  ^,  round  ligaments ;  ^^,  ovaries;  j'i,  broad  ligaments. 

In  recent  puerperal  inversion  the  cup  formed  by  the  depression 
in  the  fundus  of  the  uterus  is  usually  pronounced  and  contains  the 
tubes,  the  ovaries,  and  sometimes  intestinal  loops  (Fig.  193).  Later, 
this  cavity  is  effaced  and  there  only  remains  a  simple  opening. 
The  uterine  tumor  is  quite  large.  Its  tissue,  which  has  not  yet 
undergone  complete  involution,  is  spongy  and  vascular.  Its  surface 
is  in  contact  with  the  vaginal  mucosa.  By  attentive  examination 
there  are  discovered  two  very  narrow,  lateral  openings  about  two 
centimetres  apart,  into  which  a  hog's  bristle  can  sometimes  be 
introduced.  These  are  the  openings  of  the  tubes.  The  superior 
part  of  the  tumor,  which  is  pyriform,  is  encircled  by  the  cervical 
ling.  When  the  cervix  takes  part  in  the  inversion,  it  does  so  in  an 
unequal  degree,  more  posteriorly  than  anteriorly,  and  the  anterior 
cul-de-sac  preserves  a  greater  depth  than  the  posterior.  On  the 
uterine  mucosa  are  observed  the  macroscopic  and  microscopic 
lesions  of  glandular  endometritis. 

Chronic  inversion  without  prolapsus  forms  a  tumor  which  much 
resembles,  in  aspect  and  consistence,  a  fibrous  polypus.  The 
pedicle  is  simulated  by  the  strangled  portion  of  the  body  where 
it  passes  through  the  cervix.  The  latter  remains  in  its  normal 
position,  except  in  very  unusual  cases  where  the  inversion  is  com- 
plete. The  cer\acal  ring  then  disappears  and  the  uterine  and  the 
vaginal  mucous  membranes  are  directly  continuous.  The  mucosa 
wliieh  covers  the  tumor  in  clu'onic  inversion  often  takes  the  external 
character  of  that  of  the  vagina,  and  the  glands  disappear  in  great 
part. 

Chronic  inversion  with  prolapsus  is  very  rare.  It  is  attended 
with  ulcerations  in  consequence  of  friction  and  irritation.     The 


Inversion  of  the  Uterus.  329 

mucosa  takes  on  a  cutaneous  character  from  the  production  of 
layers  of  pavement  epithelium.  Cases  have  been  cited  where  the 
inverted  uterus  has  become  gangrenous  and  sloughed  away. 

Sijmptoms. — I  will  not  discuss  acute  inversion  at  the  moment  of 
parturition.  It  is  not  possible  to  fail  in  recognizing  it  if  the  patient 
is  examined  with  care.  It  should  be  remembered  that  if  this 
inversion  is  partial  it  may  not  be  attended  with  any  considerable 
haemorrhage.  Inversion  in  the  recent  puerperal  period  may  occur 
suddenly  and  be  accompanied  with  sharp  pain  with  severe  reflex 
phenomena,  even  syncope.  Pain,  however,  is  lacking  in  some  rare 
cases.  Haemorrhage  is  invariable.  If  the  inversion  comes  slowly, 
progi'essively,  as  is  usual  when  it  relates  to  polypi,  the  symptoms 
may  not  differ  from  those  of  a  simple  prolapsus.  The  metrorrhagias, 
however,  are  more  frequent  and  should  attract  attention.  At  the 
same  time  may  be  noted  all  the  usual  symptoms  belonging  to  the 
uterine  syndrome,  pains,  leucorrhoea,  reflex  symptoms  relating  to 
the  digestive  tract  and  to  the  nervous  system  :  finally  the  phenomena 
of  pressure  on  the  rectum  and  bladder.  The  tumor  formed  by  the 
uterus  closely  resembles  that  due  to  a  polypus,  but  bimanual  pal- 
pation assures  us  that  the  uterus  is  not  behind  the  pubes  and  that 
it  forms  the  projection  that  fills  the  vagina.  The  symptoms  of 
inversion  may  be  combined  with  those  of  a  prolapsus,  but  these 
cases  are  exceedingly  rare. 

Diagnosis.- — Two  errors  may  be  committed.  A  simple  inversion 
may  be  mistaken  for  a  polypus,  or,  where  there  is  a  complicating 
tumor,  the  inversion  may  remain  unrecognized.  Whenever  a 
supposed  polypus  prevents  a  large  pedicle  one  or  other  of  these 
errors  is  to  be  feared.  Certain  positive  symptoms  make  it  possible 
to  avoid  these  errors — the  absence  of  the  uterus  from  behind  the 
pubes,  shown  by  rectal  touch  and  by  hypogastric  palpation,  as  well 
as  by  the  sound  in  the  bladder;  a  circular  projection  limiting  a 
groove  around  the  tumor,  beyond  which  the  sound  cannot  penetrate ; 
finally,  the  openings  of  the  tubes  are  sometimes  to  be  seen ;  such 
are  the  signs  of  simple  inversion. 

Inversion  accompanying  a  polypus  is  more  difficult  to  recognize 
and  it  is  often  hard  to  decide  which  belongs  to  one  and  which  to 
the  other.  The  sensitiveness  of  the  uterine  mucosa  has  been  given 
as  in  contrast  with  the  insensibility  of  the  surface  of  the  fibrous 
body.  This  symptom  has  been  denied  and  it  is  evidently  not  of 
pathognomonic  value.  The  gi'eater  suppleness,  the  deeper  color  of 
the  uterine  tissue  are  not  strong  points,  and  the  same  is  true  of  the 
degree  of  consistence  as  appreciated  by  a  pin.  If  a  very  careful 
examination,  under  anaesthesia,  stiU  leaves  doubts,  I  believe  the 
indications  are,  after  having  thrown  a  provisional  ligature  around 
the  pedicle,  to  incise  layer  by  layer,  the  surface  of  the  tumor  to  a 
sufficient  depth  to  be  sure  that  it  does  not  contain  a  fibroid.     If,  in 


330  Inversion  of  the  Uterus. 

this  way,  the  capsule  of  a  fibrous  growth  is  found  the  tumor  should 
lie  euucleated,  aud  the  inversion  reduced  after  an  iodoform  dressing. 
If  the  incision  gives  a  negative  result  the  wound  will  he  carefuUy 
closed  by  sutures  before  removing  the  provisional  htemostatic  liga- 
ture. This  exploration  presents  no  dangers  and  obviates  the 
unfortunate  errors  that  have  been  made  in  proceeding  at  once  to 
the  total  ablation  of  the  tumor. 

Simple  uterine  prolapsus  will  give  rise  to  little  hesitation  in 
diagnosis.  The  effacement  of  the  vaginal  culs-de-sac,  the  presence, 
at  the  summit  of  the  tumor,  of  the  uterine  orifice  into  wliich  the 
sound  passes,  usually  to  an  abnormal  distance,  make  its  recognition 
possible.  The  deviation  or  the  obliteration  of  the  os  uteri  with  the 
presence  of  a  fibroid  may  make  the  diagnosis  difficult  and  such  a 
possibility  should  be  borne  in  mind. 

Prognosis. — Once  this  lesion  is  acquired  it  generally  tends  to  a 
worse  condition.  The  hemorrhages,  the  leucorrhoea,  and  the  pain 
tend  to  weaken  the  patient.  Those  rare  cases  in  which  spontaneous 
reduction  is  observed  and  those  in  which  the  uterus  is  cast  off  by 
gangrene  should  not  be  taken  into  account.  It  should  not  be  for- 
gotten, however,  that  a  remarkable  tolerance  may  be  established 
even  for  very  marked  lesions. 

Treatment. — The  nearer  the  onset  of  the  accident  the  more  easily 
will  reduction  be  effected.  Immediately  after  delivery,  after  being 
assured  that  no  debris  of  the  placenta  remain,  one  hand  should  be 
boldly  introduced  into  the  cavity  to  push  up  the  fundus  and  the 
other  hand  attempting  to  grasp  it,  wliile  strongly  depressing  the 
abdominal  wall.  In  chi-onic  cases  reduction  becomes  more  difficult. 
However,  even  very  long-standing  inversions  have  been  reduced. 
Audige  cites  one  of  thirty  year's  standing. 

The  measures  that  are  employed  for  reduction  may  be  dinded 
into  those  for  immediate  and  those  for  gradual  reduction. 

Manual  reduction. — The  patient  is  anaesthetized ;  three  fingers  are 
pushed  into  the  vagina  and  gi-asp  the  tumor ;  the  other  hand  fixes 
the  uterus  through  the  abdominal  wall  and  guides  the  direction  of 
the  pressure.  Two  manoeu\Tes  are  advised  :  the  reduction  en  masse, 
I)y  pressmg  on  the  whole  of  the  inverted  uterus ;  gradual  reduction 
from  each  cornua  separately,  inverting  successively  one  cornua 
after  the  other.  Emmet  recommends  pressing  on  the  fundus  \nth 
the  palm  of  the  hand,  while  the  attempt  is  made  to  dilate  the  eerdx 
with  the  fingers.  Courty  draws  the  uterus  down  vnth  the  volseUa 
and  introduces  two  fingers  into  the  rectum,  which  immobilize  the 
cervix  thi'ough  the  rectal  wall,  while  the  thumb  and  fii-st  finger  of 
the  other  hand  exercise  pressure  on  the  pedicle  so  as  to  increase  the 
utero-cervical  groove  little  by  little.  Courty  sometimes  makes  two 
or  three  longitudinal  incisions  to  di%-ide  the  circular  fibres  of  the 


Inversion  of  the  Uterus.  33.1 

isthmus.  Barnes  also  advises  these  incisions.  Emmet  closes  the 
orifice  of  the  cervix  with  sutures  immediately  after  the  reduction. 

Taxis  -with  instruments. — Viardel's  instrument,  in  the  form  of  a 
drumstick,  and  Wliite's  repositor,  with  a  cup  for  the  tumor  and  a 
spiral  spring  to  be  aiDplied  against  the  chest  of  the  operator,  are 
only  of  liistorical  interest.  Gaillard  Thomas,  in  a  difficult  case, 
performed  laparotomy,  dilated  the  cervical  ring  and  reduced  the 
inversion.  His  first  case  was  successful,  the  second  one  died  from 
peritonitis.  From  these  facts  it  appears  difficult  to  agree  with 
Bouilly  that  this  operation  is  to  be  recommended.  Even  for  young 
women,  hysterectomy  appears  preferable  to  the  perils  of  this  pro- 
cedure. 

Reduction  by  gradual  compression.  —  Best  in  bed,  hot  vaginal 
douches,  massage,  should  be  employed  to  diminish  the  congestion 
and  cause  a  diminution  in  the  volume.  But  continued  pressure  on 
the  organ  is  the  curative  method  paD-  excellence.  Continued  with 
persistence  it  overcomes  the  inversion  in  nearly  all  cases.  Hof- 
meier  has  never  seen  it  fail.  The  measures  that  have  been  employed 
are  various.  The  air  pessary,  Gariel's  pessary  and  the  colpeu- 
rynter  have  been  used.  A  pessary  in  the  form  of  a  cup  and  stem 
fixed  on  an  abdominal  belt  has  been  advised  by  several  authors^ 
but  it  is  dangerous,  as  it  may  give  rise  to  eschars. 

Tamponnement  with  iodoform  gauze  is  much  preferable.  Its 
employment  is  simple,  easy  and  demands  no  special  instrument. 
It  should  be  renewed  every  two  or  three  days  and  must  be  made 
each  time  with  very  gi-eat  care.  Long  strips  of  gauze,  of  two 
fingers'  width,  are  employed,  packing  them  in,  little  by  little, 
around  and  above  the  tumor,  with  some  force.  The  patient  must 
be  kept  in  the  horizontal  position  during  the  treatment,  assuring 
free  evacuation  of  the  bowels  by  enemas  and,  if  urination  is  diffi- 
cult, using  the  catheter  at  regular  intervals. 

There  remain  certain  rare  cases  where  reduction  has  been  impos- 
sible in  spite  of  long-continued  compression.  Ablation  of  the 
inverted  portion  of  the  uterus  will  then  be  legitimate,  for  inversion 
considerably  shortens  life  by  the  effects  it  produces. 

Amputation  with  the  ecraseur  should  be  rejected.  It  is  too  slow, 
gives  rise  to  severe  pain,  does  not  protect  against  haemorrhage  and 
exposes  to  injury  the  contiguous  organs.  Excision,  immediately 
preceded  by  the  application  of  a  ligature  or  a  clamp,  section  with 
the  galvano-cautery  loop,  and  the  slow  ligature,  are  procedures  that 
should  also  be  abandoned,  although,  properly  employed,  they  may 
be  successful. 

A  notable  improvement  has  been  introduced  by  Perier  in  the 
technique  of  slow  ligature.  In  place  of  applying  the  elastic  cord 
directly  on  the  point  of  strangulation,  Perier   ties   the  inverted 


33i 


Inversion  of  the  Uterus. 


utems  with  a  silk  thread,  exercising  traction  ou  this  tlu-ead  by 
means  of  a  nibber  ring.  The  constricting  ligature,  is  thus  kept 
tight  and  is  di-awn  more  and  more  into  a  hole  in  the  end  of  a  me- 
talKc  handle  which  fulfills  the  office  of  a  lever.  This  handle  is 
furnished  at  its  lower  part  \rith  a  number  of  notches  forming 
successive  points  of  support  for  the  elastic  ring  that  tightens  the 
suture  (.Fig.  194). 


Fig.  194. — Metallic  handle  fur  elastic  ligature  of  the  inverted  uterus  (Perier). 

Kaltenbach  advises  immediate  amputation  of  the  inverted  part 
with  the  knife,  after  the  application  of  a  provisional  Ugatme.  For 
greater  certainty  and  to  guard  against  possible  slipping  of  the 
elastic  cord  the  peritonaBal  surfaces  can  then  be  reunited  by  a  series 
of  deep  sutures  passing  under  all  the  raw  surface  of  the  stump  in 
such  a  way  as  to  comprise  all  the  vessels.  A  di-essiug  of  iodoform  or 
sublimate  gauze  keeps  the  stiimp  aseptic.  It  separates  about  the 
thii-d  week.  The  two  peritoua?al  folds  are  agglutinated  by  this  time 
and  do  not  leave  a  vagino-peritonfeal  fistula,  by  which  an  extra- 
uteiine  fecundation  might  be  feared.  If  the  pedicle  is  very  large  a 
double  Ligature  is  made  by  fixation. 

The  technique  of  total  vaginal  hysterectomy  is  so  well  established 
at  present,  and  its  results  are  so  satisfactory,  that  I  do  not  hesitate 
to  employ  it  in  preference  to  amputation  of  the  inverted  part  if 
the  impossibility  of  a  reduction  has  been  demonstrated. 


DefoiTnities  of  the  Cenix  Uteri..  33s 


CHAPTER  XXI. 


DEFORMITIES  OF  THE  CERVIX  UTERI. 

Atresia  of  the  cervix.  —  Atresia  is  the  imperforation  or 
occlusion  of  the  cervical  orifiee.  Congenital  atresia  is  most  fre- 
quently attended  with  other  more  important  malformations,  such 
as  double  uterus  and  vagina,  or  atrophy  of  one  of  the  two  genital 
canals.  The  study  of  hsematometra  and  hfematocolpos  wliich  result 
from  it  should  be  included  in  the  general  history  of  malformations 
of  the  genital  organs. 

In  truth,  theoretically  only,  the  description  should  be  placed  here 
of  the  rare  but  undeniable  cases,  when  the  sole  congenital  lesion 
appears  to  consist  in  the  imperforation  of  the  cervix  at  its  internal 
or  external  os.  But  the  clinical  consequences  of  this  anomaly  are 
identical  with  those  which  result  from  the  absence  of  development 
of  the  superior  portion  of  the  vagina,  and  I  would  expose  myself  to 
useless  repetitions. 

Acquired  atresia  is  consecutive  10  eschars  after  accouchement,  to 
cicatrices  following  excessive  cauterization  of  the  whole  periphery 
of  the  cervix,  to  amputations  performed  in  such  a  manner  that  the 
whole  circumference  of  the  orifice  is  iiot  bordered  with  mucous 
membrane,  and  concentric  retraction  of  the  inodular  tissue  takes 
place.  It  may  also  succeed  to  cicatrization  of  ulcerations  of  the 
cervix,  coincident  with  senile  atrophy  of  the  uterus ;  finally,  to  the 
presence  of  tumors  in  the  cavity  of  the  cervix  or  in  the  inferior  part 
of  the  iiterus  with  old  women.  Atresia  is  also  observed  in  uterine 
prolapsus,  following  the  friction  of  a  pessary  on  the  cervix  or  simply 
following  the  irritation  produced  by  the  exterior  friction  on  the  pro- 
lapsed organ.  Besides  all  these  causes,  it  may  be  spontaneously 
estabUshed  by  advancing  age.  Finally,  cases  have  been  noted, 
wliich  appear  doubtful  to  me,  of  atresia  occurring  during  the  course 
of  a  pregnancy. 

The  consequences  of  this  obliteration  are  variable  according  as 
the  woman  has  attained  or  passed  the  menopause.  In  the  first 
case,  serious  accidents,  as  haematometra  and  hsematosalpinx,  are 
to  be  feared  (I  shall  return  to  their  study  in  the  chapter  on  mal- 
formations). In  the  second  place  the  lesion  generally  passes  un- 
perceived,  unless  a  cause  of  septic  irritation  exists  in  the  interior  of 
the  uterine  cavity  and  causes  an  accumulation  of  pus  (pyometra) 
or  of  gas  (physometra).  I  have  observed  two  examples  of  pyometra 
following  cancer  of  the  uterus  and  inflamed  fibroids  in  old  women. 


334 


Deformities  of  the  Cerv'ut  Uteri. 


The  treatment  consists  in  first  re-establishing  the  permeability  of 
the  cervix  by  incisions  and  eatheterism,  if  it  is  necessary  to  dis- 
infect the  i;terine  cavity,  then  to  follow  the  indications  which  may 
be  furnished  by  a  concomitant  lesion,  fibroid  or  cancer. 

Stenosis  of  the  cervix. — Stenosis  is  the  constriction  of  the 
cervix ;  it  is  the  obstructive  dysmenorrhoea  of  English  authors. 


Fig   195. — Stenosis  of  the  cervix.     Conical  cervix.     Various  forms. 

It  may  be  congenital  or  acquired.  When  it  is  congenital  it 
generally  coincides  with  a  conical  cer%ix,  sometimes  ^vith  its 
hypertrophy,  which  is  often  in  inverse  proportion  to  the  imperfect 
development  of  the  uterus.  The  cervix,  pointed  like  a  sugar-loaf, 
presents  a  very  firm  consistence,  and  on  its  summit  is  a  little  orifice 
which  appears  to  have  been  pierced  with  a  needle  (Fig.  198).  The 
anterior  lip  often  projects  a  little,  giving  the  appearance  of  a  sort 
of  hypospadias  of  the  cervix,  or  forming  a  Kttle  tube  (tapisoid 
cervix).  The  stenosis  then  frequently  coincides  with  congenital 
hypertrophy  of  the  cervix  (Fig.  195).  Congenital  stenosis  may  be 
the  simple  consequence  of  a  cervico-corporal  anteflexion  wliich 
effaces  the  calibre  of  the  cervical  canal. 

Acquired  stenosis  is  due  to  the  same  causes  as  atresia.  One  of 
the  important  consequences  of  this  lesion  is  the  ihfliculty  of  evacu- 
ation of  the  cer^"ical  mucus,  and  in  consequence  its  stagnation  and 
the  dilatation  of  the  cavity  of  the  cervix  which  it  provokes.  This 
dilatation  is  soon  complicated  with  inflammation  of  the  mucosa, 
and  the  secondary  lesion  soon  becomes  the  preponderant  one  by 
augmenting  in  its  turn  the  abundance  and  viscosity  of  the  mucus 
(Fig.  196). 

Symptoms. — Examination  with  the  speculum  and  attempt  at 
eatheterism  leave  no  doi;l)t  of  the  existence  of   this  lesion;    the 


Deformities  of  the  Cervix  Uteri. 


BBS 


retracted  orifice  having  been  enlarged,  the  cervix  is  often  found 
dilated  like  a  bladder.  Dysmenorrhcea  and  sterility  are  the  two 
principal  symptoms.  It  is  necessary,  however,  to  note  that  dys- 
menorrhoea  is  sometimes  absent  in  women  manifestly  affected  with 
narrowness  of  the  cervix.  There  are  pains  during  the  periods, 
especially  in  the  iliac  and  sacro-lumbar  regions.  These  have  the 
character  of  colic,  coming  in  spasms  when  the  amount  of  blood  is 
too  abundant  for  the  narrowness  of  the  canal,  or  when  it  is  obstructed 
by  a  clot.  Moments  of  respite  are  observed  after  a  flow  of  blood. 
Sometimes  the  intensity  of  the  pains  is  such  that  the  patients  have 
nervous  crises,  syncope,  obstinate  vomiting,  and  come  out  of  these 
crises  in  a  state  of  extreme  prostration.  These  patients  are 
generally  chloro-aniiemic,  dyspeptic  and  neuropathic. 


Fig.  196. — Stenosis  of  the  cervix 
(external  os). 


Fig.  197. — Stenosis  of  the  cervix 
(cervical  canal). 


Metritis  is  a  frequent  consequence  of  this  difficulty  of  evacuating 
the  mucus  and  blood  proceeding  fi-om  the  internal  cavity.  The 
signs  of  the  uterine  syndrome  persist  in  the  intervals  of  the  menses, 
and  connect  the  acute  periods.  This  constitutes  one  of  the  com- 
mon forms  of  virginal  metritis. 

Sterility  is  a  consequence  of  stenosis  of  the  cervix,  although,  since 
Sims,  its  influence  in  this  particular  has  surely  been  exaggerated. 
It  is  not  so  much  by  the  mechanical  obstacle  opposed  to  the  entrance 
of  the  seminal  fluid  that  the  deformity  acts ;  however  narrow  the 
passage,  it  will  be  sufficient.  It  is  more  to  what  might  be  called 
mticus  obstruction  of  the  cervical  cavity  that  sterility  must  be 
attributed.  Normally,  at  the  moment  of  coitus,  the  cervix,  under 
the  influence  of  the  erethism,  which  Eouget  has  compared  to  a  true 
erection,  expels  the  mucus  it  contains.  In  its  place,  either  by  a 
kind  of  aspiration  resulting  from  the  cessation  of  the  venerial 
orgasm,  or  simply  by  a  capillary  effect.     Some  alkaline  vaginal 


336  Deformities  of  the  Cerrir  Uteri. 

mucus,  mixed  with  seminal  fluid,  enters  into  the  cavity;  now  this 
exchange  is  absolutely  hindered  liy  the  narro\niess  of  the  extermil 
OS,  which  maintains  the  liarrier  opposed  to  the  access  of  semen  by 
a  thick  cork  of  acid  mucus. 


Stenosis  of  the  cervix. 


Diagnosis. — The  only  interesting  and  delicate  point  is  to  recognize 
the  exact  place  where  the  maximum  of  the  narrowness  occurs. 
When  the  cervix  has  a  conical  aspect  with  punctiform  orifice,  hidden 
by  a  viscous  drop,  which  can  be  compared  to  the  small  bits  of 
mucus  coming  from  the  larynx,  there  is  no  doubt  the  external  os  is 
one  of  the  starting  points  of  the  accidents.  But  it  may  not  be  the 
only  one ;  there  is  another  strait,  as  Beimett  justly  observes,  above 
the  cervix,  where  a  contraction  may  exist  (Fig.  197). 

Can  stenosis  of  the  internal  os  be  due  to  a  contraction,  as  has 
been  maintained?  It  is  doubtful.  I  believe  it  is  the  result  of 
incomplete  development,  with  or  without  congenital  anteflexion.  I 
shall  only  remind  you  of  stenosis  acquired  by  excessive  cauter- 
ization ;  they  are  much  more  rare  there  than  at  the  external  orifice. 

We  must  be  in  no  haste  to  conclude  that  there  is  a  narrowness  of 
the  internal  orifice  becai;se  the  sound  does  not  pass  easily  at  this 
point.  We  should  be  very  sure  that  the  obstacle  is  not  due  to  the 
point  of  the  sound  being  caught  in  a  fold  of  the  mucosa,  or  against 
the  angle  of  a  flexion.  For  that  the  curve  of  the  catheter  is  modi- 
fied in  the  presumed  direction  of  the  cervico-uterine  cavity,  its 
handle  is  conveniently  lowered  toward  the  fourchette,  if  necessary 
the  posterior  lip  is  fixed,  or  drawn  on  slightly,  if  there  is  a  presumed 
anteflexion;  the  anterior  lip,  if  a  posterior  deviation.  It  is  only 
after  a  series  of  careful  attempts  that  the  diagnosis  is  established. 

Pro(/no.sis. — Stenosis  of  the  cervix  of  congenital  origin,  which  is 
incomparably  the  most  frequent,  disappears  wholly  after  fecun- 
dation and  accouchement,  not  so  much  by  the  forced  and  excessive 
dilatation  undergone  then  by  the  cervix,  as  by  the  change  of 
structui'e  which  pregnancy  imposes  on  the  entire  uterus.  The 
efforts  of  the  surgeon  ought  to  be  directed  toward  favoring  fecun- 
dation, and  he  should  only  regard  the  different  means  of  artificial 
dilatation  as  temporary  palliatives. 

Treatment. — Slow  dilatation  with  laminaria  tents,  or  immediate 
progi'essive  dilatation,  with  graduated  bougies,  have  only  ephemeral 
results  ;   they  can,  however,  be  regularly  employed  with  advantage. 


Deformities  of  the  Cervix  Uteri. 


337 


before  each  menstrual  period.  I  prefer  Hegar's  dilating  bougies, 
and  I  consider  that  their  repeated  passage  may  have  a  farorable 
etfect  by  quickening  the  vitality  of  the  moi-e  or  less  incompletely 
developed  uterus,  as  those  affected  with  congenital  cervical  stenosis 
generally  are. 

Section  of  the  external  os  by  a  sharp  instrument  may  be  made 
directly  with  the  bistoury,  with  strong  scissors,  with  special  scissors 
provided  with  a  hook  which  prevents  its  slipping  (Kuchenmeister's 
scissors),  or  with  the  different  metrotomes. 


Fig.  199. — Incision  of  tlie  cervix.     I.  Incision  with  Kuchenmeister's  scissors.     2. 
Incision  with  a  double  metrotome.     The  arc  A  B  C  indicates  the  section  obtained. 

Marion  Sims,  in  America,  popularized  this  practice  considerably, 
and  gave  it  a  reputation,  which  is  to-day  scarcely  comprehensible 
from  a  scientific  point  of  view.  Gynaecology 
has  passed,  since  then,  into  a  period,  not  yet 
ended,  in  which  incision  of  the  internal  and 
external  orifices  of  the  uterus  has  been  prac- 
ticed to  great  excess.  Now,  however  insignifi- 
cant the  operation  may  seem,  it  has  been  the 
cause  of  many  fatal  accidents,  especially 
before  the  antiseptic  era.  It  is  necessary  to 
separate  from  the  section  of  the  external 
orifice  (which  may  be  posterior  median,  bi- 
lateral or  multiple)  the  section  of  the  internal  the  cervix  (cervical  caaal). 
orifice  and  the  whole  extent  of  the  cervical  -^ ''' ""^^  °f '"=i^i°"- 
canal  (Fig.  200).  The  incisions  can  be  made  with  a  blunt  bistoury 
after  fixing  the  cervix  and  drawing  it  slightly  downward.  Tliis 
operation  is  much  more  serious  than  the  preceding. 

To  arrest  the  htemorrhage,  the  incision  is  tamponed  with  cotton 
plugs  soaked  with  perchloride  of  iron,  wliich  are  removed  the 
following  day.     The  patient  should  be  kept  in  bed  for  three  days. 


338  Deformities  of  the  Cervix  Uteri. 

A  small  elastic  stem-pessary  (Barnes),  or  a  glass  stem-pessary 
(Thomas)  is  kept  in  the  cervix  several  days.  I  shall  not  stop  to 
describe  these  operations  farther,  for  I  consider  them  useless.  The 
incisions  of  the  external  orifice  Ijeeome  cicatrized  and  reproduce 
the  deformity,  or  remain  gaping,  and  cause  eversion  of  the  mucosa 
and  pei-petuate  the  cervical  catarrh.  As  to  the  deep  incisions  they 
are  not  without  danger,  for,  however  carefully  the  play  of  the 
metrotome  is  regulated,  this  instrument,  which  acts  Hke  a  needle, 
may  pass  the  expected  limits  and  give  rise  to  accidents.  I  would 
prefer  the  blunt  bistoury,  which  is  controllable. 

Dilatation  of  the  cer\-ix  by  the  different  procedures,  bloody  or  not, 
may  give  excellent  results  in  a  special  class  of  patients,  that  is,  in 
cases  of  slight  stenosis  accompanied  with  disproportionate  nervous 
reflex  phenomena.  Two  theories  have  been  advanced  on  this 
subject.  Schauta,  who  praises  section  with  the  sharp  instniment, 
claims  to  have  thus  cured  hysteriform  neurosis.  He  attributes  the 
result  to  the  section  of  the  nerve  filaments ;  he  declares  that  in  such 
cases  non-bloody  dilatation  fails  completely.  On  the  other  hand, 
Doleris  recommends  forced  dilatation  of  the  cervix  under  the  same 
circumstances,  which  he  thinks  acts  by  nerve  stretching.  I  believe 
that  in  either  method  the  rapid  improvement  of  the  patients  may  be 
explamed  much  more  simply  by  the  easy  escape  of  the  mucous 
secretions  which  were  till  then  retained.  A  constant  source  of 
reflex  disturbance  is  thus  removed.  It  is  not  only  the  pains,  but 
the  gastric  troubles  winch  are  thus  rapidly  relieved. 

Electrolysis  has  been  strongly  recommended  of  late.  Its  ad- 
vantages are,  harmlessness,  absence  of  pain,  efficacy,  due  to  the 
fact  that  the  eschar  of  the  negative  pole  leaves  a  soft  and  yielding 
cicatrix  like  that  of  a  caustic  alkali.  Long-contimied,  very  weak 
currents  are  recommended. 

In  cases  where  the  stenosis  of  the  cervix  is  not  very  great  I  prefer, 
to  these  complicated  means,  the  immediate  progi-essive  dilatation 
with  Hegar's  bougies  (after  softening  the  cervix  mtli  laminaria 
tents).  I  combine  this  manoeuvre,  if  necessary,  with  very  slight 
division  of  the  border  of  the  cer\-ical  orifice,  with  a  blunt  tenotome, 
to  open  at  first  the  ijassage  for  a  fine  laminaria  tent.  In  cases  of 
very  pronounced  stenosis,  the  only  rational  operation  appears  to 
me  to  be  the  autoplastic  reconstruction  of  the  orifice  sufficient  for 
the  cervix  by  a  stomatoplastic  operation.  This  operation  acts 
not  only,  as  might  be  believed,  on  the  construction  of  the  external 
orifice,  but  by  the  profound  modifications  of  vitality  which  it  causes 
in  the  cervix.  The  superior  part  of  the  canal  becomes  more  per- 
meable. It  acts,  finally,  also  by  destroying  the  cervico-corporal 
flexion  where  the  bending  often  gives  the  impression  of  a  superior 
narrowing.  I  believe,  then,  that  after  having  made  this  operation 
some  time  should  lie  permitted  to  elapse  before  attacking  a  stenosis 


Defoo-mities  of  the  Cennr  ZTteri.  339 

located  above  and  its  existence  verified  by  a  previous  examination. 
Later,  it  may  be  found  that  the  apparent  obstruction  has  disap- 
peared ;  if  it  still  exists,  progressive  dilatation  with  Hegar's  bougies 
is  infinitely  preferable  to  incision ;  the  passage  of  the  first  bougies 
is  favored  by  very  slight  internal  scarifications  with  a  tenotome ;  but 
they  are  nothing  compared  to  the  deep  incisions  of  Simpson,  Sims, 
and  others. 

The  stomato-plastic  operation  is  only  an  amputation  of  the  cervix. 
I  have  described  its  technique  in  the  chapter  on  treatment  of  metritis. 
I  shall  not  return  to  it.  One  or  other  of  the  procedures  I  have 
explained  is  chosen  according  to  the  case.  If  we  have  to  deal  with 
a  thick,  fleshy  cervix,  the  biconical  excision  (Simon-Marckwald), 
with  two  flaps,  may  be  resorted  to.  If  the  mucosa  is  manifestly  much 
altered,  one  should  rather  adopt  the  method  with  one  flap  with 
excision  of  the  mucous  membrane  (Schroeder).  I  have  sometimes 
combined  these  two  methods  for  a  conical  cervix,  making  two  flaps 
on  the  anterior  lip  so  as  to  remove  a  more  considerable  cuneiform 
segment,  only  one  flap  on  the  inferior  lip.  However,  the  end  which 
should  especially  be  sought  is  to  reconstruct  an  orifice  in  the  form 
of  a  transverse  slit,  and  of  suflicient  dimensions,  very  exactly 
surrounded  by  the  mucous  membrane,  so  that  no  post-operative 
retraction  or  narrowing  can  be  produced. 

Congenital  atrophy  of  the  cervix  and  of  the  uterus. — 
There  exists  a  so-called  congenital  atrophy  which  it  would  be  better 
to  regard  as  congenital  by  predisposition,  or  simply  by  evolution. 
The  uterus  may,  after  birth,  undergo,  not  an  arrest  of  development, 
as  during  the  fcetal  period  (arrest  which  constitutes  a  malformation 
by  the  absence  of  certain  parts  of  the  uterus),  but  a  general  failure 
of  development ;  without  altering  its  type  this  arrest  of  growth 
leaves  the  adult  uterus  undersized  like  that  of  a  cliild.  The  entire 
organ  is  small,  the  walls  thin,  but  the  proportions  of  the  cer^dx  and 
the  body  are  normal  (which  distinguishes  it  from  the  fcetal  uterus). 
It  is  this  that  Puech  has  called  the  pubescent  uterus,  to  show  that  it 
preserves  the  dimensions  of  the  beginning  of  puberty ;  Virchow  has 
given  it  the  name  of  hypoplasia  of  the  uterus.  Generally,  the  other 
genital  organs,  internal  and  external,  are  also  atrophied. 

The  weight  of  the  pubescent  uterus  is  less,  according  to  Puech, 
than  that  of  the  normal  virginal  uterus ;  it  is,  on  an  average,  twenty- 
seven  grammes,  instead  of  forty-five  grammes.  This  infantile  state 
of  the  genital  organs  coincides  sometimes  in  the  woman  (as  also 
in  men)  with  an  imperfect  development  of  the  entire  organism, 
and  girls  may  be  seen,  over  twenty  years  of  age,  having  the  size  and 
appearance  of  girls  who  have  not  yet  arrived  at  puberty.  At  other 
times,  the  atrophy  remains  limited  to  the  sexual  apparatus  and 
nothing  betrays  the  defect  externally  except  great  narrowness  of  the 
pelvis.     There  is,  in  short,  an  intimate  correlation  between  the 


340  Deformities  of  th<;  CervU  Uteri. 

condition  of  this  part  of  the  skeleton  and  that  of  the  internal  genital 
organs.  In  mathematical  language,  it  maj'  he  said  that  the  pelvis 
is  developed  in  relation  to  the  uterus.  The  exceptions  to  this  rule 
are  rare. 

It  is  to  congenital  predisposition  of  obscure  origin  that  atrophy 
must  be  attributed.  It  has  been  said  that  it  sometimes  depends  on 
chlorosis  or  tuberculosis.  The  reverse  appears  to  me  nearer  the 
tnith.  Women  affected  ^ith  this  malformation  have  a  more  or  less 
morbid  nervous  system  and  a  very  poor  general  nutrition  by  reason 
of  the  same  genital  lesion. 

Symjytoms  and  diarinosis. — Complete  amenorrhcea,  or  almost  com- 
plete, first  attracts  attention.  The  menstmal  molimen  may  even 
be  wanting,  and  the  young  girl  has  really  no  sex,  in  the  physio- 
logical point  of  view.  If  the  menses  appear  they  are  attended  with 
dysmenorrhcea  and  gi-ave  nervous  disturbances.  A  certain  pro- 
portion of  these  patients  are  affected  with  a  hereditary  neurotic 
taint,  and  belong  to  the  class  alienists  call  degenerate ;  their  intelli- 
gence is  feeble ;  they  have  attacks  of  hysteiia  or  epilepsy.  This  is, 
however,  not  general ;  another  class  of  women  with  the  pubescent 
uterus  possess,  on  the  contrary,  a  robust  constitution  in  every  other 
respect.  Local  examination  shows  the  cervix  very  small,  the  orifice 
narrow;  bimanual  palpation,  rectal  touch,  the  use  of  the  soimd, 
indicate  atrophy  of  the  iitei-us  itself ;  the  external  genital  organs  are 
generally  little  developed,  the  vagina  short.  The  normal  proportions 
of  the  cervix  in  the  pubescent  uterus  distinguish  it  fi-om  the  fcetal 
or  infantile,  when  the  cervix  is  very  much  developed  while  the  body 
is  atrophied. 

Treatment.  —  The  general  health  should  fii-st  receive  attention ; 
tonics,  reconstructives,  hydrotherapy,  sojourn  by  the  seaside,  ^^'ill 
improve  the  health  and  gi'owth  of  the  patient.  Local  treatment 
is  of  little  service .  It  has  been  advised  to  excite  the  uterus  by 
pessaries  with  galvanic  stems  (iron  and  cupper)  giving  feeble 
electric  currents  acting  in  every  case  as  local  excitants.  This  is  a 
means  which  is  not  free  from  difficulty  and  even  danger ;  its  useful- 
ness is,  moreover,  problematical.  Dii'ect  application  of  the  electrical 
current  would  be  more  rational.  The  symptomatic  treatment  should 
be  insisted  upon  to  relieve  the  sufferings  of  dysmenorrhcea.  If  this 
and  the  nervous  symptoms  are  of  an  aggravated  character  we  are 
authorized  in  assuming  that  the  development  of  the  ovaries  is  out  of 
proportion  to  that  of  the  litems  ;  should  this  be  found  to  be  the  case, 
on  pelvic  examination  under  eliloroform,  castration  T^ill  be  indicated. 

Acquired  atrophy  or  superinvolution  of  the  cervix 
and  body  of  the  uterus.  —  PathohHiical  tviatomy  and  (etioloijy. — 
Normally  the  end  of  genital  life  with  women  is  marked  by  a  dimi- 
nution of  the  volume  of  the  uterus,  which  progresses  with  age  ;  so 
pronounced  is  this  atrophy  in  very  old  women  that  the  utenis  is 


Deformities  of  the  Cervix  Uteri.  341 

reduced  to  a  mere  nodule.  Such  is  commonly  the  case  at  least,  if 
it  does  not  contain  fibroid  nuclei.  Senile  atrophy  takes  place  at  the 
same  time  in  the  body  and  the  cervix ;  tliis  last  is  often  only  a  shape- 
less stump,  or  has  even  disappeared  to  the  extent  of  leaving  only  the 
orifice  at  the  end  of  the  vagina.  It  is  especially  with  women  who 
have  had  many  children  that  this  fact  is  observed. 

Sometimes  an  analogous  process  is  established  prematurely, 
before  the  normal  period  of  the  menopause,  and  that  after  a  con- 
finement when  it  seems  as  if  all  the  vitality  of  the  uterus  is  exhausted 
at  one  blow.  Normal  involution  in  these  cases  proceeds  beyond  the 
physiological  limits.  Simpson  has  found  this  atrophy  in  about  one 
and  a  half  per  cent  after  accouchement  and  Frommel  in  one  per  cent. 
But  it  must  be  noted  that  these  superinvolutions  are  sometimes  only 
temporary.  Frommel  considers  prolonged  lactation  one  of  the  chief 
causes  of  superinvolution.  Copious  haemorrhages  at  the  time  of 
confinement  seem  to  have  a  marked  influence ;  finally,  the  same  is 
true  of  all  exhausting  diseases — tuberculosis,  chlorosis,  syphilis, 
diabetes,  Bright's  disease,  morphinism,  Basedow's  disi^ase,  etc. 
Sometimes  diseases  of  the  genital  organs  terminate  in  uterine  atro- 
phy ;  pi'olonged  metritis,  oophoro-salpingitis  may  end  in  atrophy  of 
the  uterus.  Pelvic  peritonitis  during  the  puerperal  state,  or  better^ 
septic  peri-oophoro-salpingitis  which  may  follow  confinement  or 
abortion,  by  causing  sclerosis  of  the  ovary,  may  also  be  the  cause 
of  premature  menopause  and  superinvolution. 

Finally,  I  have  remarked  that  the  diminution  of  volume  of  the 
body  of  the  uterus,  which,  as  Braun  has  shown,  follows  ampu- 
tations of  the  cervix,  may  go  on  even  to  atrophy  of  the  uterus. 
With  an  old  woman  affected  with  prolapsus,  on  whom  I  practiced 
conoid  amputation  of  the  cervix  according  to  Huguier's  method 
four  years  ago,  the  uterine  body  is  reduced  to  the  size  of  a  nut.  In 
a  j^oung  woman  whose  cervical  mucosa  I  excised  for  intense  metritis 
of  the  cervix,  the  uterus  immediately  became  greatly  reduced  in 
size,  finally  returning,  however,  to  its  normal  condition. 

Ablation  of  the  ovaries  is  also  a  cause  of  atrophy  of  the  uterus, 
and  some  authors  have  not  hesitated,  in  consequence,  to  practice 
castration  for  the  relief  of  ohi-onic  painful  metritis.  In  the  case  of 
senile  atrophy,  the  uterine  tissue  is  sclerosed ;  in  the  post-puerperal 
superinvolution,  it|  may  be  softened  and  friable  in  consequence  of 
the  incomplete  reabsorption  of  the  fatty  materials  proceeding  from 
the  disintegration  of  the  muscular  fibres. 

Symptoms  and  diagnosis. — The  cessation  of  the  menses  and  the 
small  size  of  the  cervix  and  body,  proved  by  the  different  modes  of 
exploration,  constitute  in  themselves  the  clinical  picture.  It  is 
necessary  to  recommend  the  greatest  care  in  the  use  of  the  sound 
in  post-puerperal  atrophies,  the  wall,  perhaps,  having  become  thin. 
In  cases  of  senile  atrophy  the  depth  is  only  five  to  six  centimetres, 


342 


Deformities  of  the  Cervix  Uteri. 


while  in  the  ease  of  post-puerperal  snperinvolution,  the  cavity  is 
normal,  hut  may  appear  enlarged  hy  reason  of  the  yielding  character 
of  the  uterine  tissue. 

Prognosis  and  treatment. — It  is  possible  that  the  post-partum 
superinvolution  may  be  only  temporary,  and  numerous  observations 
prove  that  fecundation  and  pregiaancy  may  follow  it .  The  functional 
activity  of  the  uterus  should  be  stimulated  by  the  use  of  general 
tonics,  hydrotherapy,  salt  baths,  application  of  electricity  to  the 
uterus  and  a  local  excitation  by  hot  douches  and  the  often-repeated 
passage  of  the  sound  in  the  uterine  canity.  I  prefer  these  means 
to  the  use  of  a  galvanic  or  elastic  stem-pessary,  which  appears  to 
me  more  injurious  than  useful.  Perimetritic  inflammations  have 
been  known  to  follow  their  use. 

Hypertrophy  of  the  supravaginal  portion  of  the 
cervix. — The  hypertrophy  may  pei-tain  to  the  supravaginal  portion 
of  the  cer\ax  or  affect  its  infravaginal  portion.  I  have  ah-eady 
described  this  lesion  in  connection  with  prolapsus  of  the  genital 
organs,  which  it  frequently  accompanies.  I  refer  the  reader  to  that 
chapter. 


Fio.  20I. — Hypertrophy  of  the  supravaginal  portion  of  the  cervix. 

Polaillon  has  observed  a  case  in  wliich  not  only  the  supravaginal 
part  of  the  cervix  but  also  the  uterine  body  had  undergone  a  gigantic 
hypertrophy;  the  uterus  occupied  the  whole  abdomen,  without 
alteration  of  its  form  and  -without  tumor.  These  exceptional  cases 
of  a  gigantic  uterus  must  not  be  confounded  with  supravaginal 
hypertrophy  of  the  cervix.    Hypertrophy  depending  on  the  presence 


Deformities  of  the  Cervix  Uteri. 


343 


of  a  fibroid,  will  be  equally  well  distinguished  by  the  special  symp- 
toms they  induce.  The  only  common  symptom  in  all  these  cases 
is  the  unusual  depth  to  which  the  sound  penetrates. 


Fin.  202. — Hypertrophy  of  the  cervix,  with       FiG.  203. — Hypertrophy  of  the  cervix, 
elongation  of  the  supravaginal  portion.  with  bilateral  laceration. 

Hypertrophy  of  the  infravaginal  part  of  the  cervix. — 

^Etiology  and  patholociical  anatomy. — I  shall  not  stop  long  to  describe 
here  the  acquired  hypertrophy  consecutive  to  metritis,  which  has 
been  previously  studied ;  I  shall  only  recall  that  it  may  take  two 
forms — follicular  hypertrophy,  affecting  especially  the  mucosa, 
infiltrating  the  glands  of  new  formation  that  have  more  or  less 
undergone  cystic  degeneration;  sclero-cystic  hypertrophy,  where 
the  parenchyma  of  the  cervix  is  distended  by  the  adventitious  pro- 
duction of  connective  tissue,  fasciculi  and  the  presence  of  numerous 
little  cysts  or  Nabothian  glands.  The  first  of  these  forms  is  especially 
fungous,  soft  to  the  touch ;  the  second,  tuberculous,  and  of  firm  con- 
sistence. They  often  give  the  cervix  the  form  of  a  club  or  of  the 
tongue  of  a  bell  (Figs.  202  and  208). 

Very  different  in  aspect  and  structure  are  the  congenital,  or 
developmental  hypertrophies,  which  appear  atthe  time  of  the  evo- 
lution of  the  uterus,  at  puberty,  and  are  more  or  less  pronounced 
eventually.  Here,  it  is  not  a  change  of  texture  due  to  inflammation 
which  causes  the  increase  in  volume.  There  appears  to  be  hyper- 
plasia of  all  the  elements  simultaneously,  without  deviation  from 
the  normal  type ;  the  mucosa  is  healthy.  The  cervix  is  very  much 
elongated,  conical  or  cylindrical,  others  tapering  Iw  excessive  pro- 


844  Deformities  of  tli£  Cerviv  Uteri. 

jeetion  of  the  anterior  liiJ.  It  may  fill  the  vagina  and  pass  the 
vulvar  orifice,  forming  thus  a  projection  which  the  woman  takes  for 
prolapsus  of  the  uterus.  At  the  end  of  the  tumor  an  orifice  is  seen, 
generally  very  small,  from  which  a  drop  of  mucus  escapes.  Stenosis 
of  the  external  orifice  frequently  coexists  "with  this  deformity  and  I 
have  already  noted  this  coincidence  (Fig.  195). 

Symptoms  and  diagnosis. — The  signs  of  dysmenorrhoea  often  pre- 
cede the  appearance  of  the  tumor  at  the  edge  of  the  ^nilva.  These 
are  the  chief  symptoms  in  young  girls ;  married  women  experience  a 
sharp  pain  during  coitus  (dyspareunia).  If  the  hyijertrophy  of  the 
cervix  is  very  great,  the  penis  thi-ows  it  in  front  and  opens  a  sort  of 
false  vaginal  canal  by  depressing  the  posterior  cul-de-sac,  whose 
depth  is  found  considerably  increased.  Pains,  leucorrhcea,  metror- 
rhagia, comj)lete  the  uterine  syndrome.  By  touch  and  examination 
with  speculum  the  nature  of  the  tumor  is  easily  recognized;  the 
persistence  of  the  uterine  body  in  its  normal  place  excludes  pro- 
lapsus or  inversion;  the  continuity  of  the  hypertrophied  cei-vix 
with  the  body,  the  existence  of  the  external  orifice  on  its  summit, 
distinguish  it  from  polypus.  Careful  exploration  by  bimanual 
palpation  and  the  sound  will  show  whether  in  addition  to  this 
Bubvaginal  lesion  there  is  a  greater  or  less  degree  of  supravaginal 
hypertrophy  of  the  cervix. 

Prognosis  and  treatment. — The  tumor  once  formed  has  no  tendency 
to  regression.  Surgical  interference  is  the  onlj' resource.  Biconical 
amputation  of  the  cervix  is  the  procediare^^rtr  exceUence.  If  haemor- 
rhage is  feared,  an  elastic  cord  may  be  thro'mi  around  the  cervix 
above  a  strong  needle  pushed  thi'ough  it  below  the  insertion  of  the 
vagina,  to  prevent  its  shpping.  My  elastic  ligator  renders  this 
manoeuvre  particularly  easy. 

After  amputation  of  the  infravaginal  portion  of  the  cervix,  the 
supravaginal  part,  which  was  hypertrophied,  may  undergo  a  com- 
plete regression. 


Precocious  and  Late  Menstriuitwn.  345 


CHAPTER  XXII. 


PRECOCIOUS   AND  LATE   MENSTRUATION. 

In  our  temperate  climate,  menstruation  generally  commences 
toward  fifteen  years  of  age  and  ends  at  forty- seven,  thus  giving  to 
the  woman  a  genital  life  of  about  thirty-two  years.  Women  be- 
ginning menstruation  early,  continue  a  little  later.  Numerous 
examples  are  known  where  the  establishment  of  puberty  occurs  in 
very  young  children.  The  pubes  is  covered  with  hair,  the  external 
genital  organs  and  the  breasts  become  prematurely  developed; 
finally,  the  menses  appear,  to  be  regularly  maintained,  or  to  cease 
at  the  end  of  some  years.  On  the  cadaver  of  a  child  of  four  years, 
who  had  menstruated  thi-ee  years  of  its  existence,  Campbell  found 
an  excessive  development  of  the  genital  apparatus.  Procbownick, 
who  was  able  to  make  an  autopsy  on  a  little  girl  of  three  years,  who 
had  menstruated  one  year,  was  able  to  make  out  all  the  signs  of  an 
old  and  recent  ovulation.  Young  girls  have  been  known  to  become 
pregnant  in  these  conditions  at  a  very  early  age — eight,  ten,  eleven 
and  twelve  years.  Precocious  puberty  is  not  confined  to  women. 
I  have  seen  an  example  of  similar  precocity  in  a  man.  We  are 
much  more  hable  to  fall  into  error  in  regard  to  late  menstriaation. 
Any  intermittent  haemorrhage,  even  irregular,  is  easily  taken  by  a 
woman,  still  in  the  neighborhood  of  the  menopause,  as  a  continuance 
of  the  menses,  especially  if  there  has  not  been  an  interval  of  great 
length  between  these  periods.  It  often  then  is  due  to  uterine  dis- 
ease till  then  unsuspected — endometritis,  mucous  poljrpus,  fibroid 
tumors  and  especially  cancer.  However,  undoubted  examples  of 
late  menstruation  have  been  cited,  lasting  up  to  fifty-six  and  fifty- 
seven  years. 


346  Ameiiwrlia-ti. 


CHAPTER  XXIII. 


AMENORRHCEA. 

By  amenorrlioea  is  meant  the  absence  of  menstruation  and  not 
the  absence  of  the  regular  flow  by  the  genital  canal.  In  fact,  it 
may  be  that  menstruation  is  not  absent,  but  only  latent,  as  in  cases 
of  retention  of  the  menstrual  fluid  by  atresia,  etc.  These  two 
conditions  should  be  carefully  distinguished.  In  the  last,  the 
amenorrhoea,  which  may  be  caUed  obstructive,  is  only  a  secondary 
symptom  and  I  shall  return  to  its  consideration  in  the  chapter 
on  malformations  of  the  genital  organs.  Primitive  or  permanent 
amenorrhcea  occurs  where  the  menses  have  never  made  then- 
appearance  ;  it  has  also  been  called  emansio  mensinm.  Temporary, 
or  better,  secondary  or  accidental  amenorrhcea,  has  also  been 
called  suppressio  mensium. 

Pathogeny ;  ^-Etioloyy. — One  might  say  that  the  feminine  organism, 
during  the  period  extending  from  puberty  to  the  monopause,  has  a 
double  existence :  that  of  the  hidividual ;  that  of  the  species ;  that 
of  all  the  organs  in  general ;  that  of  the  geuital  apparatus  in 
particular.  This  duahty,  whose  physiological  and  psychological 
consequences  are  so  important,  may  be  interrupted  by  the  influence 
of  a  disease,  just  as  it  ceases  under  the  influence  of  age. 

Amenorrhcva  is  nothing  more  than  the  absence  or  suspension  of 
the  genital  Hfe,  produced  either  by  organic  insuflieieucy  or  by  a 
profoiind  disturbance  of  the  general  nutrition  of  the  iudi%"idual.  It 
is  necessary  to  look  from  this  point  of  ^iew  to  fully  understand  the 
unexpected  and  excessive  disorders  caused  sometimes  by  the  dis- 
turbance of  this  equiUbrium.  The  geuital  apparatus  is  not,  so  to 
speak,  an  accessory  mechanism  in  the  feminine  organism ;  on  the 
contrary,  it  constitutes  the  principal  part.  AU  abdominal  economy 
is  ordered  with  special  reference  to  the  possibihty  of  conception. 
The  Hindoos,  not  whoUy  without  reason,  consider  all  menstruation 
■which  has  not  been  preceded  by  coitus,  as  an  infanticide  :  they  also 
marry  their  young  gu-ls  immediately  before  puberty,  to  save  them 
from  even  a  fii'st  crime.  It  might  be  said  as  well,  with  a  paradoxi- 
cal conciseness,  that  the  normal  state  of  woman  is  pregnancy  or 
lactation.  During  these  periods  menstniation  ceases,  only  to  return 
when  the  excess  of  nutritive  material  is  not  thus  utilized.  Mensti-u- 
ation  is  then  a  safty-valve  ;  its  absence  is  the  sign  of  a  diminished 
nutritive  activity  where  it  is  not  the  normal  result  of  a  utilization 
of  its  materials  in  the  reproduction  of  the  species. 


Amenorrhoea.  347 

A  resume  of  the  conditions  of  a  regular  menstruation  may  be 
made  as  follows :  (a)  Integrity  of  the  genital  apparatus ;  (b) 
Normal  composition  of  the  blood ;  (c)  Normal  state  of  the  nervous 
system.  A  disturbing  influence,  however,  having  one  or  another 
of  these  origins,  may  prevent  the  maturation  of  the  ovule,  or 
disturb  ovulation,  or  hinder,  by  inMbitory  action  on  the  great 
sympathetic  and  the  vasomoters,  the  intense  congestion  which  is 
the  immediate  cause  of  the  menstrual  flow. 

Lesions  of  both  ovaries,  cysts,  sclerosis,  periovaritis,  act  directly 
on  the  starting  point  of  the  reflexes,  and  if  they  are  sufficiently 
advanced,  may  abohsh  it  completely.  But  it  is  more  commonly  the 
case  that  these  lesions,  not  ha%'ing  entirely  destroyed  the  organ, 
play  the  role  of  excitants,  and  produce  metrorrhagias  with  dys- 
menorrhoea  in  place  of  amenorrhoea. 

Does  bilateral  ablation  of  the  ovaries  surely  cause  cessation  of 
the  menses  ?  This  question,  the  reply  to  which  has  been  for  a  long 
time  apparently  settled,  has  recently  been  revived  by  a  great  many 
contradictory  observations.  One  important  distinction  should  be 
made  from  the  start.  The  same  value  should  not  be  accorded  to 
observations  in  eases  where  ovarian  tumors,  cystic  or  papillary, 
have  been  removed  and  in  those  where  castration  has  been  performed 
for  very  insignificant  lesions,  with  but  slight  alteration  in  the  volume 
and  connections  of  the  organ,  as  sclero-cystic  degeneration,  or  even 
on  altogether  healthy  ovaries  (Battey's  operation).  Observations 
in  the  first  class  of  cases  should  be  rejected  since  it  is  impossible  to 
affirm  with  certainty  in  the  case  of  large  tumors,  whether  one  has 
left  a  fragment  of  ovarian  tissue  in  the  pedicle ;  that  alone  suffices 
for  the  continuance  of  the  menstrual  reflex. 

There  remains  a  great  mass  of  undeniable  evidence  fi-om  the  two 
last  classes  of  cases,  when  in  spite  of  double  castration,  menstruation 
has  continued,  more  or  less  irregularly.  But  it  is  to  be  noted  that, 
every  time  a  patient  has  been  kept  under  observation  during  the 
lapse  of  a  very  long  time,  these  prolonged,  and  so  to  speak,  posthu- 
mous menstruations  have  been  found  to  cease  at  the  end  of  some 
months.  It  is  not  then  necessary  to  assume,  as  has  been  done,  the 
possible  existence  of  a  supplementary  ovary ;  it  is  sufficient  to 
recall  the  well  known  law  of  the  persistence  of  organic  habits.  It 
is  weU  known  that  the  nervous  system  of  vegetative  life,  like  that  of 
the  life  of  relation,  can  reproduce,  so  to  speak,  automatically  and 
under  the  influence  of  an  old  stimulus,  such  acts  as  congestion  of 
the  genital  apparatus.  It  is  then  like  a  continued  movement  by 
the  fact  of  acquired  velocity,  but  which,  in  the  absence  of  a  fresh 
impulse,  quickly  becomes  weak  and  stops. 

One  circumstance  which  may,  however,  favor  the  ephemeral  pro- 
longation of  the  menstrual  molimen,  is  the  presence  of  alterations 
of  the  uterine  mucosa  and  its  parenchyma,  constant  in  the  case  of 


348  Amenorrhoea. 

fibroids  when  castration  has  been  performed,  very  frequent  in  the 
inveterate  oophoro-salpingitis  for  which  the  appendages  are  removed. 
Also,  I  beheve  in  all  these  cases,  the  termination  of  the  principal 
operation  by  a  supplementary  curetting  should  never  be  neglected. 

Czempin  also  attributes  some  importance  to  the  passive  con- 
gestion due  to  compression  of  the  veins  by  the  cicatricial  tissue, 
resulting  fi-om  the  operation. 

Amenorrhoea  following  castration  generally  coincides  with  certain 
physical  changes,  increase  of  embonpoint,  atrophy  of  the  breasts, 
and  sometimes  a  marked  change  of  temper,  which  becomes  more 
placid.  Ablation  of  the  tubes  alone  does  not  appear  to  influence 
menstruation  if  the  ovaries  are  healthy  ;  this  sets  aside  the  opinion 
of  Lawson  Tait  on  the  preponderating  mfluence  of  these  organs  upon 
this  function. 

Primary  amenorrhoea  may  be  due  to  a  bad  nutrition,  a  defective 
hygiene,  retarding  the  general  development  of  the  organism ;  intel- 
lectual strain  and  the  absence  of  exercise,  in  some  schools  and 
convents  have  produced  amenorrhoea  as  well  as  chlorosis.  It  is  well 
understood  that  young  girls  having  hereditary  scrofulous  antecedents 
and  who  are  praticularly  debiUtated,  are  more  especially  predisposed 
to  it.  Change  of  regime,  a  nitrogenous  and  an  abundant  nourish- 
ment substituted  suddenly  for  an  exclusively  vegetable  diet,  the 
absence  of  exercise  when  accustomed  to  the  open  air,  with  young 
country  girls  coming  to  live  in  the  city,  aU  by  producing  a  sudden 
plethora,  appear  to  have  sometimes  caused  a  delay  in  the  appearance 
of  the  menses. 

Secondary  amenorrhoea  may  be  caused  by  poverty  of  blood  and 
a  profound  state  of  debility  in  the  course  of  a  chronic  disease,  or 
succeeding  an  acute  disease.  Ansemia,  chlorosis,  Bright's  disease, 
diabetes,  alcoholism,  morphinism,  cancerous  or  paludal  cachexia, 
pulmonary  tuberculosis,  convalescence  from  great  pyrexias,  act  in 
this  way.  Acute  or  chi'onic  sm-gical  affections  may  in  the  same 
manner  cause  amenorrhoea. 

It  is  still  to  the  profound  anaemia  which  accompanies  the  invasion 
of  the  diathesis  that,  without  doubt,  should  be  attributed  the 
syphilitic  amenorrhoea  on  which  Fournier  has  insisted,  and  that  of 
young  women  affected  with  polysarca,  which  is  often  a  very 
debilitating  dystropliia*.  The  influence  of  the  nervous  system  is 
considerable  in  the  production  of  amenorrhoea. 

Fright  often  produces  a  temporary  suspension  of  the  menses. 

It  is  the  moral  depression,  as  much  as  the  auismia,  caused  by  the 
seclusion,  to  which  the  amenorrhoea  of  prisoners  is  due,  or  of  lunatics 
confined  in  an  asylum.  Chlorosis,  which  causes  amenorrhoea, 
appears  to  be  really  a  disease  of  the  nervous  system.  The  absence 
of  the  menses  is  very  frequent  with  hysterical  persons.     Sudden 


Amenorrhcea.  349 

cold,  which  is  often  noted  as  an  occasional  cause  of  amenorrhcea, 
acts,  probably,  through  the  vaso-motors. 

It  is  to  the  inhibitory  power  of  the  nervous  system  that  it  is 
necessary  to  attribute  the  emotional  amenorrhcea  of  newly-married 
women  or  of  women  ardently  desiring  to  have  children ;  its  coinci- 
dence with  a  certain  degree  of  tympanites  has  often  caused  illusions 
and  cruel  deception.  There  is  an  amenorrhcea  which  might,  be 
attributed  to  fear,  in  women,  who,  in  consequence  of  an  irregular 
liaison  or  for  other  reasons  fear  pregnancy  (Eaciborske).  I  have 
observed  many  examples  of  the  different  varieties.  The  last  two  are 
not  without  some  analogy  with  auto  suggestions.  Suggestion  has  an 
undoubted  influence  with  a  certain  class  of  subjects. 

Atrophy  of  the  uterus  by  exaggerated  involution  after  repeated 
pregnancies,  prolonged  lactation,  etc.,  produces  amenorrhcea. 

Symptoms. — Absence  of  the  flow  of  blood  by  the  genital  passages 
at  the  regular  periods,  constitutes  the  principal  sign.  But  it  is 
necessary  not  to  omit  the  concomitant  nervous  symptoms  which 
may  sometimes  be  very  serious,  and  which  are  presented  under  the 
type  of  chlorosis  or  of  hysteria.  Some  sensory  troubles,  feebleness 
of  sight,  of  hearing,  paraplegia,  appear  to  be  as  much  direct  results 
of  amenorrhcea  as  hysteria  alone.  Amenorrhcea  coincides  in  some 
cases  with  periodic  cutaneous  eruptions  which  appear  at  the  time 
of  the  menses.  Acne,  eczema,  herpes,  urticaria,  pemphigus,  ery- 
sipelas, hyperidi-osis,  and  swelling  of  face  and  feet  have  also  been 
noticed,  no  doubt  from  angioneurosis. 

These  facts  lead  to  the  curious  study  of  vicarious  menstruation. 
They  indicate  the  organic  consensus  and  the  possible  substitution 
which  may  exist  between  the  external  tegument  and  the  uterine 
mucosa.  There  are  in  science  curious  cases  of  what  might  be 
called  supplementary  secretions.  George  E.  Jones  has  reported 
a  case  of  a  young  woman,  who  after  a  suppression  apparently  due  to 
a  sudden  chill,  was  affected  with  amenorrhcea  and  presented  for 
five  years,  in  place  of  menses,  an  abundant  flow  of  milk  from  the 
breasts,  lasting  thirty-six  hours.  Another  woman  having  had  many 
children  had,  during  the  three  first  days  of  the  catamenial  period, 
an  abundant  diarrhoea  with  leucorrhoea,  which  terminated  in  the 
appearance  of  a  little  blood.  He  also  cites  an  example  of  periodic 
leucorrhoea  in  place  of  menses. 

Deviation  of  the  menses,  supplementary  or  vicarious  menstru- 
ation or  ectopic,  presents  the  most  curious  and  the  most  unexpected 
examples.  One  of  the  most  frequent  avenues  is  the  bronchial  or 
pulmonary  mucosa ;  the  patient  has  regular  hgemoptysis  which  may 
be  mistaken  for  a  commencing  phthisis.  Also  have  been  observed 
hsematemesis,  epistaxis,  rectal  haemorrhage,  particularly  with 
plethoric  women   affected  with   haemorrhoids,   otorrhagia,   either 


350  Amenorrhcea. 

when  there  had  existed  previously  a  persistent  otorrhcea  which  had 
made  this  place  a  locus  minorus  resistent'ue,  or  even  when  the 
tympanic  membrane  was  healthy.  More  rare  are  cutaneous  haemor- 
rhages in  the  form  of  ecehymoses  and  petechiae.  I  have  seen  at  the 
St.  Louis  hospital,  an  infirm  woman,  affected  with  lupus  of  the  face, 
who  had  at  each  menstrual  period,  an  abundant,  bloody  oozing  in 
tins  place. 

Treatment. — It  is  an  error  to  think  that  amenorrhcea  requires 
special  medication,  destined  to  have  an  elective  action  on  the  uterine 
mucosa.  The  emmenagogues,  rue,  sabiua,  saffron,  apiol,  can  at 
the  most  be  useful  in  limited  cases  when  a  very  obvious  occasional 
cause  (cold,  violent  emotion)  has  produced  the  cessation  of  the 
menses.  At  the  time  of  the  missing  menses  they  must  be  given 
only  with  moderation.  I  may  say  the  same  of  very  hot  baths  (40' 
C.  to  45°  C).  Drastic  and  saline  purgatives  might  also  be  given 
to  provoke  a  certain  degree  of  pelvic  congestion.  Eecently  per- 
manganate of  potash  has  been  extolled  as  a  sovereign  remedy. 

Ordinarily  it  is  the  casual  indication  which  must  be  observed  and, 
as  amenorrhcea  is  under  the  influence  either  of  a  poverty  of  blood  or 
a  nervous  disorder,  it  is  to  reconstructives,  tonics,  general  altera- 
tives and  in  particular  to  iron  and  manganese,  or  to  hydi-otherapy, 
that  recource  must  be  had.  I  attach  much  more  importance  to  this 
general  treatment  than  to  scarifications  of  the  cer^dx,  the  appli- 
cation of  a  galvanic  pessary,  etc.  Electricity  (Faradic  and  continued 
currents)  may  give  good  results  and  should  not  be  neglected. 
Bigelow  recommends  in  the  amenorrhcea  of  ehloro-anfemic  young 
gu-ls  static  electricity  as  a  general  tonic.  In  the  intermittent  form 
of  amenorrhcea,  with  plethoric  women,  the  coutiuous  current  is 
found  beneficial,  the  positive  pole  being  placed  in  the  uterine  cavity ; 
with  virgins,  one  pole  is  placed  on  the  lumbar  region  and  the  other 
at  the  level  of  the  uterus,  externally;  with  anaemic  women  not 
virgins,  one  pole  is  placed  by  preference  in  the  uterus  and  one  pole 
on  the  hjTpogastiium.  Bigelow  is  also  a  great  partisan  of  general 
electrization  in  amenorrhcea,  one  pole  placed  on  the  mxcha,  the  other 
in  a  salt  foot-bath ;  he  praises  this  means  particularly  with  nervous, 
irritable,  and  chlorotic  young  girls.  The  treatment  should  be 
commenced  some  days  before  the  menstraal  date,  and  a  daily  appH- 
cation  be  made  up  to  the  time.  We  should  prescribe,  also,  especially, 
physical  exercise,  out-of-door  walks,  gymnastics,  a  sojourn  at  the 
seaside  or  in  the  mountains — fi]ially  mental  diversion  and  absence 
of  all  moral  preoccupation. 

In  the  ease  of  amenorrhcea  with  young  girls,  threatened  or  affected 
with  obesity,  I  have  often  caused  the  return  of  the  menses  by 
attacking  the  obesity,  by  the  dry  diet,  abstinence  from  feculents, 
exercise,  the  thermal  treatment — finally  by  the  stimulation  of  the 


Menorrhagia.  351 

uterine  mucosa  by  the  aid  of  the  curette,  followed  by  iodine  injections 
at  the  menstrual  date. 

With  women  who  have  undergone  castration  and  remamed 
amenorrhceic,  it  is  not  rare  to  observe,  in  the  first  months  which 
follow  the  cessation  of  menstruation,  the  appearance  of  some  periodi- 
cal disturbance,  consistmg  of  lumbar  pains,  flashes  of  heat,  vertigo, 
irritability  of  a  special  character — in  a,  word  a  true  molimen — -which 
is  the  more  painful  as  it  is  only  slowly  dissipated  in  the  absence 
of  the  natural  crisis.  In  these  cases,  I  have  found  scarification  of 
the  cervix  very  useful  by  causing  a  small  local  bleeding  every  month 
at  regular  periods.  I  advise  the  use  of  saHne  purgatives.  One  of 
my  patients  has  come  regularly  for  more  than  a  year  to  have  this 
little  operation  performed,  which  gives  her  immediate  relief.  In 
time,  these  symptoms  disappear  spontaneously. 


CHAPTER  XXIV 


MENORRHAGIA. 

Exaggeration  of  the  menstrual  flow  constitutes  menorrhagia; 
metrorrhagia  is  distinguished  from  it  by  the  irregular  appearance 
of  the  blood. 

Symptoms. — Excess  and  long  duration  of  the  flow,  clots,  general 
weakness — such  are  its  characteristics.  These  phenomena  consti- 
tute, not  a  disease,  but  the  symptoms  of  many  diseases. 

Etiology;  Pathogeny. — Tavo  categories  of  causes  may  produce  it: 
1.  General  causes  which  act  by  changes  of  the  blood :  of  this  order 
are  all  dyscrasic  diseases — hfematophilia,  purpura,  scorbutus,  grave 
icterus,  poisoning  by  phosphorus,  Bright's  disease,  Werloff's  disease, 
polysarca  and  aU  the  cachexias.  Amenorrhoea  alternating  with 
menorrhagia  is  then  sometimes  seen.  2.  Local  causes  are :  (a). 
Reflex  excitation,  having  their  starting  point  in  the  genital  organs 
(and  in  particular  the  appendages)  independent  of  all  appreciable 
lesion  and  by  simple  nervous  derangement,  as  at  the  time  of  puberty, 
defloration,  the  menopause.  In  this  class  ought  also  to  be  included 
metrorrhagias  provoked  by  lactation,  no  doubt  by  the  reflex  exci- 
tation on  the  part  of  the  breast,  (b).  Almost  all  the  diseases  of  the 
uterus  and  appendages,  metritis,  fibroids,  cancer,  ovarian  tumors, 
especially  those  wliich  are  very  close  to  the  uterus,  as  intraliga- 
mentous cysts,  affections  of  the  tubes.     I  shall  confine  myself  here  to 


352  Mennrrkaciia. 

this  enumeration,  for  I  have  only  tn  trace  a  framework  and  not  to 
make  a  complete  picture ;  these  few  scattered  traits  will  he  more 
useful  in  the  statement  of  each  affection  in  particular. 

Treatment. — These  symptoms  should  be  treated  singly  only  when 
they  assume  a  disturbing  importance.  It  is  always  necessary,  at 
the  same  time,  to  seek  to  attack  the  cause.  I  shall  then  simply 
recall  here  the  empirical  haemostatic  means  which  are  at  the  disposal 
of  the  surgeon.  The  fu-st,  local,  an  especially  prolonged  irrigation 
with  very  hot  water  (43^  C.  to  50"  C.)  and  tamponnement  of  the 
vagina.  Emmet  first  employed  the  temporary  suture  of  the  cervix, 
which  can  be  used  in  cases  where  all  other  means  have  failed. 
Martin  sometimes  practices  Kgature  eii  7)iasse  of  the  inferior  branches 
of  the  uterine  artery  thi-ough  the  vaginal  culs-de-sac.  I  have  seen 
this  means  succeed  m  his  hands.  The  general  measures  will  be 
simultaneously  employed :  rest  in  bed  with  slight  elevation  of  the 
pelvis,  opium  m  the  form  of  laudanum  enemas,  ergot  by  the  stomach 
and  by  hypodermic  injection.  Gaillard  highly  praises  the  infusion 
of  digitalis  leaves. 

Finally,  if  the  haemorrhage  becomes  threatening,  are  we  justified, 
even  in  the  absence  of  a  positive  diagnosis,  in  undertaking  a  radical 
operation?  Vaginal  hysterectomy  may,  in  such  cases,  appear 
legitimate,  even  for  haemorrhagic  endometritis  that  has  resisted  all 
other  treatment.  Others  have  used  castration,  which  is  a  more 
benign  operation  and  quite  as  efficacious.  Olshausen  cites  the  case 
of  a  woman  of  tliirty-nine,  attacked  with  menorrhagia  so  obstinate 
that  in  spite  of  the  absence  of  any  appreciable  lesion,  he  practiced 
castration  for  this  sjTiiptom  alone,  Tsith  the  greatest  success.  It  is 
always  necessary  to  be  on  our  guard  against  magnifying  these  ex- 
ceptions into  a  therapeutic  rule,  and  Walton  opposed,  with  good 
reason,  the  extreme  views  of  some  surgeons. 


Dysmenorrhcea.  353 


CHAPTER  XXV. 


DYSMENORRHCEA  AND  NERVOUS  DISTURBANCE 
OF  MENSTRUAL  ORIGIN. 

Normally,  at  the  menstrual  period,  women  are,  as  they  say, 
unwell ;  that  is  to  say  they  feel  a  general  malaise,  some  vague  pains 
in  the  back  and  a  peculiar  irritability  of  temper.  But  these  symp- 
toms are  usually  but  slightly  marked.  When  menstruation  becomes 
very  painful  and  is  accomplished  with  difficulty  it  is  a  dysmenor- 
rhcea. The  recognized  vai'ieties  have  become  numerous ;  we  have : 
1.  Neui'algic  or  sympathetic  dysmenorrhcea ;  2.  Congestive  or  in- 
flammatory ;  3.  Mechanical  or  obstructive ;  4.  Membraneous ;  5. 
Ovarian.  This  classification  may  be  much  simplified  and  all  forms 
included  in  two  subdivisions,  according  as  they  are  produced  during 
the  ovario-tubular  stage  (maturing  of  the  follicle,  ovulation),  or 
during  the  uterine  stage  (expulsion  of  the  menstrual  blood). 

Dysmenorrhcea  of  ovarian  origin  may  i-esult  fi-om  an  m-egular 
development  of  the  genital  organs,  either  the  ovaries  having,  like  the 
uterus,  remained  in  a  pubescent  state,  or,  on  the  contrary,  the  uterus 
having  fallen  behind  in  point  of  development  the  ovaries  reaching 
the  adult  state  in  advance  of  it.  There  is  then  an  inevitable  irregu- 
larity in  the  process  of  menstruation,  by  reason  of  the  difficulty  of 
ovulation,  or  by  the  disproportion  which  exists  between  the  intensity 
of  the  congestive  symptoms  on  the  side  of  the  ovary  during  o^Tilation 
and  the  precarious  state  of  the  attendant  congestion  of  the  uterus. 
From  this  comes  an  abnormal  exaggeration  of  the  ovarian  erethism 
and  the  pains  of  dysmenorrhcea. 

Diseases  of  the  appendages  are  another  very  frequent  cause.  I 
speak  not  only  of  acute  inflammations  or  grave  morbid  conditions 
such  as  salpingitis,  hydro-,  hemato-  and  pyo-salpinx,  but  of  the 
effects  of  former  inflammations,  often  attracting  but  little  attention, 
such  as  adhesions,  false  membranes,  partially  strangulating  the 
appendages  or  dislocating  them  into  an  abnormal  position,  causing 
sclerosis  of  the  ovary  and  obliteration  of  the  tube,  that  are  the  very 
frequent  and  often  unknown  causes  of  intense  pain  at  the  time  of 
the  menses.  Tubo-ovarian  varicocele  (Richet),  varicose  dilatation  of 
the  pampiniform  plexus  and  of  the  veins  of  the  broad  ligament  are 
possible  letiological  factors ;  they  are  frequently  accompanied  also 
with  chronic  ovaritis  and  atrophy  of  the  ovary,  as  atrophy  of  the 
testicle  follows  varicocele  in  the  other  sex. 

Dysmenorrfiaa  of  uterine  origin. — The  cause  of  this  disturbance  is 


354  Dysiiuuorrh(ea. 

the  mechanical  obstacle  to  the  expulsion  of  the  blood ;  thus  act 
stenosis  of  the  cervix  with  or  without  hyi^ertrophy,  ile\iations  of  the 
utenis,  particularly  flexions,  metritis  (swelling  of  the  diseased 
mucosa  and  accompanying  salpingitis),  different  tumors,  fibroids, 
mucous  polypi,  cancers.  I  have  described  with  acute  metritis  the 
special  form  which  is  attended  with  complete  desquamation  of  the 
mucosa  and  which  constitutes  the  artificial  disease  created  by 
authors  under  the  name  of  membraneous  dysmenorrhcea.  Is  there 
reason  to  distingiiish  a  diathetic  dysmenorrhcea,  gouty  or  rheumatic  ? 
I  think  not ;  it  can  only  be  said  that  the  arthritic  are  specially  liable 
to  different  forms  of  neuralgias. 

Symptoms  and  diac/nosis. — The  pains  of  dysmenorrhoea  have  a 
different  character,  according  to  their  starting  point.  It  is  at  the 
commencement  of  menstruation  that  ovarian  i^ains  predominate, 
and  it  is  at  its  height  that  uterine  pains  are  accentuated. 

The  so-called  intra-meustrual  dysmenorrhcea  is  so  termed  only  by 
an  abuse  of  language.  This  name  has  been  given  to  pains  in  the 
ovarian  regions  occurring  now  and  then  in  the  interval  between  the 
periods  and  attributed  hypothetically  to  ovulation.  These  are  the 
symptoms  of  inflammation  of  the  utenis  or  the  appendages. 

I  have  before  described  the  character  of  the  pains  of  dysmenor- 
rhcea ;  I  shall  not  recur  to  these  at  gi'eat  length.  Habitually  the 
pams  appear  with  the  flow  and  are  most  violent  the  first  two  days. 
Sometimes  even  in  the  absence  of  mechanical  obstruction  or  narrow- 
ing of  the  cer^•ix,  the  blood  comes  di-op  by  drop  only,  like  the  urme 
in  strangury,  from  Avhich  comes  the  name  stiUickUum  uteri,  applied 
to  this  phenomena  by  ^Etius.  The  appearance  of  small  clots  is 
the  indication  of  stagnation  of  blood  in  the  uterine  cavity,  and  their 
expulsion  coincides  with  paroxysms  of  colic,  sometimes  very  intense, 
causing  hysteriform  crises  and  even  syncope.  The  menstrual 
period  may  become  very  painful  after  ha\ing  been  for  a  long  time 
painless  ;  this  is  observed  particularly  ui  some  cases  of  salpingitis 
passing  fi-om  the  acute  into  the  clnonic  stage. 

The  diagnosis  should  first  distinguish  true  dysmenorrhoea  fi"om 
the  lumbo- abdominal  neuralgias  brought  on  at  the  time  of  the 
menses  and  which  may  simulate  it;  the  coexistence  of  the  neu- 
ralgias and  search  for  the  painful  points  vd\l  help  to  clear  up 
the  diagnosis.  Afterward,  to  distuiguish  between  pains  of  ovarian 
and  those  of  uterine  origin,  a  careful  analysis  of  the  local  symptoms 
win  be  necessary.  The  symptoms  observed  pre\"ious  to  the  menses 
will  aid  materially.  The  consideration  of  these  different  questions 
is  treated  in  coimection  ^^"ith  the  several  diseases  I  have  enumerated. 

I  shall  especially  describe  the  dysmenorrhcea  and  gi'ave  reflex 
symptoms  wliich  may  be  produced  Ijy  prolapsus  of  the  ovary.  On 
digital  examination  a  tumor  is  found  in  Douglas'  cul-de-sac  which 
is  sensitive  and  causes  nausea  under  pressure.     Two  concomitant 


Dysmenorrhoea.  355 

symptoms  are,  pain  in  defecation  and  pain  in  coitus,  dyschezia  and 
dyspareimia. 

Battey,  and  many  gynsecologists,  especially  in  America,  have 
attached  very  great  importance  to  the  co-existence  of  menstrual 
ailments,  amenorrhoea  and  dysmenorrhoea,  with  serious  nervous 
disorders,  hysteria,  epilepsy,  mania;  thus  have  been  created  the 
words  oopltoral[/la,  oophorepile'psy,  oophoromania.  It  is  not  to  ''be 
disputed  that  a  certain  proportion  of  these  diseases  are  dependent 
upon  a  pathological  reflex  from  the  badly  developed  or  diseased 
ovaries.  But  the  difficulty  of  precise  diagnosis  is  extreme,  and  the 
surgeon  should  be  correspondingly  guarded.  Beside  a  small  number 
of  very  clear  cases  where  the  preponderant  influence  of  the 
menstrual  period  is  evident,  and  when  the  ovarian  congestion  seems 
to  be  the  starting  point  of  the  aura,  for  example,  in  epilepsy,  there 
are  a  great  number  where  the  menstrual  ailments  are  merely 
coincident,  having  no  causal  relation  to  the  remote  disease. 

As  palliative  measures  for  relief  of  pains,  we  may  employ  bromide 
of  potassium,  chloral,  valerianate  of  ammonia,  asafoetida,  musk, 
tincture  of  cannabis  indica,  belladonna  and  hyoscyamus.  Antipyrine 
in  hypodermic  injections  is  a  valuable  measure ;  in  the  most  intense 
crises  the  cautious  use  of  ether  by  inhalation  may  be  employed. 
Oxalate  of  cerium  has  been  praised.  Wylie  thinks  a  great  deal  of 
electricity;  he  places  the  positive  pole  in  the  cavity  of  the  cervix. 
Laudanum  enemas,  with  valerian,  sometimes  procure  relief  when 
other  remedies  have  failed. 

The  general  treatment  will  be  directed  to  the  anaemic  or  the  neu- 
rotic condition  of  the  patient.  The  curative  treatment  does  not 
permit  of  general  indications.  It  varies  essentially  according  to  the 
cause  of  the  dysmenorrhoea.  If  it  is  manifestly  in  the  uterus  or 
the  appendages,  it  is  the  initial  lesion  which  should  be  attacked.  In 
cases  where  the  existence  of  this  lesion  is  doubtful,  or  the  patient 
suffers  from  functional  disorders  of  uncertain  origin,  the  treatment 
is  extremely  difficult.  In  truth,  we  may  often  hope  to  see  the  dis- 
ease disappear  almost  spontaneously  by  the  progress  of  age, 
marriage  and  fecundation,  in  a  great  many  eases,  when  it  is  due  to 
imperfect  development  of  the  internal  genital  organs,  with  or  with- 
out stenosis  of  the  cervix.  There  are  cases,  however,  where  the 
parallelism  is  never  established  between  the  functions  of  the  ovary 
and  of  the  uterus.  There  are  others  where  these  functions  are 
definitely  disturbed  by  acquired  lesions  (adhesions,  displacements), 
which  permanently  impede  the  functions  of  the  ovary.  The  peri- 
odic pains  become  intolerable  and  impair  the  general  health. 
Besides,  disorders  often  serious,  epile^jsy,  mania,  have  been  thought 
to  have  a  reflex  origin  and  to  result  directly  from  dysmenorrhoea. 
It  is  in  these  cases  that  extirpation  of  the  healthy  ovaries  has  been 
practiced,  to  cure  the  pain  by  abolisliing  the  function  which  caused  it. 


356  Dysmenorrhoea. 

This  special  indication  for  oophorectomy,  castration,  or  normal 
ovariotomy  (term  which  signifies  that  the  ovary  has  presen'ed  its 
normal  size)  was  first  proposed  by  Battey,  in  America,  then  by 
Hegar,  in  Germany,  and  Lawson  Tait,  in  England.  According  to 
Battey,  whose  operation  has  retained  his  name,  before  resorting  to 
castration  in  such  cases,  the  surgeon  should  ask  himself  the  foUowing 
questions:  1.  Is  the  case  serious?  2.  Is  it  curable  by  other  medi- 
cal or  sm-gical  means  ?  3.  Is  it  curable  by  the  estabhshment  of  the 
menopause  ?  Truly,  all  the  difficulty  is  in  this  last  point.  It  is 
not  enough  that  the  ovary  is  veiy  painful,  to  make  one  certain  that 
it  is  the  starting  point  of  the  disease;  one  should  remember  the 
hysterical  ovary;  moreover,  ovarian  pain  may  exist  in  any  woman 
with  neuralgic  pains  having  a  central  origin  with  centrifugal  radi- 
ations. Often  healthy  teeth  are  extremely  sensitive  in  neuralgia  of 
the  trigemini :  no  one  would  think  of  having  them  extracted. 
Objection  has  been  made  to  the  remark  of  Olshausen  that,  castration 
being  very  benign  in  these  cases  when  the  ovary  is  not  diseased  and 
the  pains  being  violent,  many  patients  will  consent  to  an  operation 
which  offers  them  even  uncertain  chances  of  cure.  It  will  at  least 
have  the  effect  of  abohshing  the  constant  exacerbations  at  the  time 
of  menstmation. 

For  menstraal  epilepsy,  Lawson  Tait  has  had  very  encouraging 
results.  However,  G.  WiUers,  Hegar's  pupU,  has  made  some 
observations  which  prove  that  there  is  more  hope  of  a  cure  if  the 
ovaiy  is  injured  than  when  it  is  healthy.  The  same  is  true  in 
hysteria  and  hystero-epUepsy  with  notable  exacerbation  at  the  time 
of  the  menses  and  assumed  or  known  lesion  of  the  ovanes. 

Castration  has  had  its  successes,  many  of  them,  however,  more 
apparent  than  real:  though  its  results  are  sometimes  biilliant  it 
may  wholly  fail  or  give  only  temporally  rehef.  Finally,  it  should  be 
asked  if  its  beneficial  effects  are  not  sometimes  the  result  of  strong 
moral  impression  and  a  trend  of  suggestion  produced  by  the  oper- 
ation. We  have  evidence  of  this  in  the  happy  effect  which  has  been 
produced,  exceptionally  by  a  pretended  castration.  As  to  castration 
for  mania  or  psychosis  apparently  uifiuenced  by  menstruation,  I 
believe  they  should  be  rejected  without  hesitation.  A  case  has  been 
cited  where,  far  fi"om  obtaining  relief,  the  symptoms  were  aggi'avated 
by  the  operation.  We  cannot  sympathize  vdih  sui'geons  who  have 
practiced  castration  to  cause  sterilits-  and  prevent  the  reproduction 
of  hereditary  mania. 

In  the  preceding  considerations  I  have  not  alluded  to  anatomical 
lesions  of  the  ovaries.  In  spite  of  the  very  praiseworthy  efforts  of 
Hegar  to  confine  casti'ation  to  cases  where  lesionsof  the  ovary  can  be 
made  out,  and  to  give  to  this  operation,  even  when  practiced  for  the 
relief  of  nervous  ailments,  an  anatomical  basis,  he  does  not  doubt 
that  the  diagnosis  is  altogether  important  in  an  immense  majority 


Dysmenorrhcea.  357 

of  cases.  Sclero-cystic  degeneration,  cii-rhosis  and  hyperplasia  of 
the  stroma,  can  very  rarely  be  recognized  by  bimanual  palpation, 
and  as  to  the  signs  to  which  such  lesions  give  rise,  there  is  nothing 
to  distinguish  them  fi'om  purely  nervous  affections. 

It  does  not  appear  doubtful  to  me,  that  ablation,  even  of  the 
healthy  ovaries,  has  modified  the  condition  of  the  nervous  system, 
so  as  to  cause  the  disappearance  of  grave  reflexes  of  the  menstrual 
function.  In  consequence,  the  principal  thought  of  the  operator 
should  not  be  so  much  to  know  if  the  ovary  he  is  about  to  remove 
presents  an  anatomical  lesion,  as  to  assure  himself  that  it  is  the 
physiological  starting  point  of  these  accidents ;  the  examination  of  the 
rational  signs  surpasses  here  the  physical  examination.  But  it  must 
be  stated  that  it  is  very  difficult  to  decide,  and  unless  with  a  well- 
supported  conviction,  a  conscientious  surgeon  wiU  always  shi'ink 
from  an  operation,  which,  when  it  is  useless,  constitutes  a  veritable 
mutilation,  much  more  serious  in  the  social  point  of  view  than  the 
amputation  of  a  member.  Pean  prefers  to  ovarian  castration,  vagi- 
nal hysterectomy,  which  he  calls  uterine  castration;  he  finds  it 
superior  to  ablation  of  the  ovary,  even  for  the  cure  of  nervous 
symptoms.  The  fact  appears  doubtful  a  priori,  seeing  the  much 
greater  richness  of  nervous  connections  with  the  ovary.  Besides,  it 
is  incontestable  that  oophorectomy  is  a  much  less  serious  operation 
than  hysterectomy. 

Technique  of  castration. — I  have  already' described  this  operation 
in  connection  mth  the  indirect  treatment  of  fibroids;  only  some 
special  points  need  to  be  noted  here.  The  abdominal  incision 
should  be  as  small  as  possible,  for  it  is  only  made  to  pass  the  ovary 
and  tube  without  laborious  search  or  difficult  disengagement, 
besides,  there  is  always  time  to  enlarge  it  secondarily.  Six  to  eight 
centimetres  is  generally  sufficient  to  determine  the  exact  place  of 
incision.  The  exact  situation  of  the  fundus  of  the  uterus  should  be 
found  by  bimanual  exploration,  and  the  middle  of  the  incision  be 
carried  to  this  level ;  the  inferior  extremity  of  the  wound  is  generally 
two  finger  breadths  from  the  pubes.  Battey,  at  least  in  his  first 
operations  only  removed  the  ovary.  Hegar  has,  from  the  begin- 
ning, comprehended  the  importance  of  simultaneous  ablation  of 
the  tube  which,  besides,  facilitates  the  operation  more  than  it 
complicates  it.  Lawson  Tait  has  done  much  to  convert  oopho- 
rectomy into  salpingo-oophorectomy.  The  cicatrix  left  by  a  small 
incision,  such  as  Lawson  Tait  practices,  is  altogether  insignificant, 
especially  when  care  is  taken,  as  I  have  recommended,  to  suture 
the  abdominal  walls  by  three  superposed  rows  with  two  tiers  of 
buried  sutures  of  catgut. 

Vaginal  incision  offers  few  advantages  from  this  point  of  view. 
However,  castration  may  be  practiced  in  this  way  to  avoid  a  visible 
cicatrix  when  the  patient  expresses  a  marked  preference  for  it  and 


S-'iS  Inflammation  of  the  Uterine  Appeiidafies. 

especially  when  tlie  prolapsed  ovaries  are  easily  accessible.  The 
prolapsed  ovaries  are  easily  recognized,  in  Douglas'  cul-de-sac,  by 
vaginal  touch  and  also  to  two  characteristic  signs :  pain  during  defe- 
cation, and  pain  during  coitus. 

The  operation,  when  the  uterus  is  very  movable,  is  of  gi"eat 
simplicity :  the  patient  being  in  the  dorso-sacral  position,  a  short 
Simon's  speculum  depresses  the  fourchette,  the  cervix  is  fixed  and 
drawn  forward,  an  assistant  lowers  the  uterus  by  pressing  on  the 
hypogastrium.  A  transverse  incision  of  four  centimetres  is  made 
in  the  posterior  cul-de-sac  as  near  the  uterus  as  possible.  The 
index  and  middle  fingers  are  introduced  into  Douglas'  cul-de-sac, 
the  ovary  and  tube  taken  hold  of,  the  pedicle  transfixed  with  a 
blunt  needle  and  tied  with  Lawson  Tait's  knot.  It  is  better  to 
remove  the  appendages  of  both  sides,  even  if  only  one  ovary  is  pro- 
lapsed, when  there  are  very  marked  nervous  disorders,  for  the 
artificial  menopause  acts  much  more  surely  than  the  suppression  of 
the  displaced  organ.  If  the  operation  has  not  been  disturbed  by 
any  accident  and  there  is  no  special  reason  to  make  drainage,  the 
wound  is  completely  closed  with  catgut  sutures. 


CHAPTER  XXVI. 


INFLAMMATION   OF   THE  TJTERINE 
APPENDAGES. 

In  the  attempt  to  understand  the  close  connections  between  the 
uterus  and  the  Fallopian  tubes,  it  must  be  remembered  that  they 
have  a  common  embryonal  origin.  At  the  end  of  the  second  mouth 
of  intrauterine  life,  MiUer's  di;cts  fuse  iuferiorly  to  form  the  uterus 
and  the  vagina,  while  they  remain  distmct  above  and  constitute  the 
tubes.  The  latter  are  in  reahty  only  the  slender  prolongation  of  the 
uterine  cornua.  There  is  an  immediate  continuity  between  their 
different  coats,  from  which  arises  the  possibility  of  an  ascending 
salpingitis  consecutive  to  metritis,  even  as  an  ascending  pyelitis  is 
consecutive  to  an  inveterate  cystitis.  The  ovary,  connected  to  the 
tube  by  the  tubo-ovarian  ligament,  is  in  almost  immediate  contact 
with  its  pavilion  and  may  be  infected  by  contiguity.  These  organs 
are  also  united  by  importiint  vascular  and  lymphatic  connections. 
I  need  scarcely  remind  the  reader  of  the  anastomoses  of  the  utero- 
ovarian  arteries  and  veins  M"ith  those  of  the  uterus.  Still  more 
important    are    the    lymphatics.     Championniere    has    described, 


Tnfiammaiion  of  the  Uterine  Appendages. 


359 


especially  at  the  angles  of  the  uterus,  superficial  lymphatics  which 
are  lost  in  the  broad  ligament  behind  and  below  the  tube,  between 
the  tube  and  the  round  ligament,  and  especially  below  the  ovary 
and  the  tube.  Deep  lymphatics  also  exist,  forming  a  second  plane, 
that  are  only  seen  by  cutting  the  uterine  angle  perpendicularly. 
There  is  a  remarkable  lymphatic  group  occupying  the  space  between 
the  tube  and  the  ligament  of  the  ovary.  Important  relations, 
completing  the  already  close  anatomical  connections,  are  thus 
established  between  the  ovary  and  the  tube.  Thus  there  is,  so  to 
speak,  no  ovaritis  without  salpingitis  and  no  salpingitis  without 
ovaritis;  the  inflammations  of  the  appendages  are,  then,  properly 
combined  in  the  same  description. 


Fig   204  — Fillopian  tubes     normal  state      A    Section  near  the  uterus 
B.  Near  the  pavihon  (Wyder). 

Almost  always  the  inflammation  passes  from  the  tube  to  the  ovary 
directly  by  contact  and  by  adhesion.  But  sometimes  there  is  also 
observed  a  suppuration  of  the  ovary  without  continuity  with  the 
inflammation  of  the  tube.  This  fact  can  then  be  explained  by  the 
lymphatic  relations.  The  vessels  which  come  from  the  pavilion 
follow  the  external  lateral  ligament  and  empty  into  the  large 
lymphatic  plexus,  called  the  subovarian  plexus.  There  is  then  no 
difficulty  in  comprehending  that  an  abscess  of  the  ovary  may  be 
observed  with  relatively  small  lesions  of  the  oviduct.  The  adhesions, 
which  are  rich  in  lymphatics,  may  serve  to  carry  the  inflammation. 


360 


Injiammatioit  of  the  Uterine  Appeiuhujes. 


The  lymphatic  network  which  covers  the  surface  of  the  ovary 
also  communicates  extensively  with  that  of  the  peritouitum .  Accord- 
ing to  Wal clever,  it  is  sufficieut  to  puncture  the  ovai-y  with  a  tube 
for  lymphatic  injection  to  fill  all  the  network  of  the  abdominal 
serosa.  If,  then,  the  peritonitis  consecutive  to  inliammation  of 
these  organs  usujilly  remains  circumscribed,  it  is,  without  doubt^ 
because  an  early  stage  of  the  processes  consists  in  a  plastic  obhter- 
ation,  in  a  sort  of  adhesive  lymphatic  thrombosis. 


Finally,  the  subperitoneal  cellular  tissue  that  exists  in  the  wings 
of  the  tube  and  of  the  ovary  is  in  connection  with  that  of  broad 
ligaments,  which  is  itself  continuous  below  on  the  pelvic  flcx>r  and 
on  the  sides  with  lamellar  tissue  folding  in  with  the  peritonfeum 
and  offering  a  special  laxity  in  fi-ont  of  the  bladder,  in  the  pseudo 
cavity  of  Eetzius  (Fig.  '206).  The  knowledge  of  these  peculiarites  is 
indespensable  for  the  explanation  of  the  deep  and  the  superficial 
propagation  of  the  inflammation. 


Infiamnmtioii  oj  the  Uterine  Appendages. 


361 


Fig.  206.— Pseudo  cavity  (Retzius) 

The  classifications  of  salpingitis  that  have  been  given  differ 
markedly.  Cornil  and  Perrillon  admit:  1.  Vegetating  catarrhal 
salpingitis.  2.  Purulent  salpingitis  (pyosalpinx).  3.  Hsemorrhagic 
salpingitis  (hsemato-salpiux,  haematoma  of  the  tube).  4.  Blennor- 
rhagic  salpingitis.  5.  Tubercular  salpingitis.  THs  classification 
is  incomplete,  for  it  leaves  out  certain  forms  of  diffuse  interstitial 
inflammation  that  are  met  in  the  chronic  affections.  It  is  a  little 
at  fault  in  separating  the  tubercular  and  blennorrhagic  forms  from 
purulent  salpmgitis,  as  they  are  only  simple  varieties  of  the  latter. 
Orthman  makes  this  division :  1.  Catarrhal  salpingitis,  with  the 
varieties :  simple,  diffuse,  blennorrhagic,  haemorrhagic,  follicular. 
'2.  Purulent  salpingitis,  which  may  be  septic,  blennorrhagic  or 
tubercular.  3.  Haematosalpinx.  4.  Hydrosalpinx.  ,5.  Pyosalpmx 
(or  purulent  cystic  salpingitis). 

From  both  the  clinical  and  anatomical  point  of  view,  I  believe  it 
is  important  to  divide  the  inflammations  according  as  they  do  or  do 
not  terminate  in  the  formation  of  an  encysted  tumor.  We  then  have : 

((a).  Acute  catarrhal.  f  Hypertrophic,  or  vegetating 

I    Non-cvstic saloinaitis   J  f'^''  Acutepurulent.  J       variety. 

1  ('^)-  Chronic  parenchymatous   j  Atrophic,  or  sclerous  vari- 
[  (pachysalpingitis).  |      ety. 

{(a).  Hydrosalpinx,  or  serous. 
(b).  Hsematosalpinx,  or  hemorrhagic. 
{c].  Pyosalpinx,  or  purulent. 

I  do  not  in  this  classification  take  the  aetiologj'  into  account,  for  a 
blemiorrhagic  salpingitis  may  evolve,  according  to  the  most  diverse 
types :  type  purulent  non-cystic,  purulent  cystic,  or  pyosalpinx, 
which  may  be  ulteriorly  transformed  into  hydrosalpiux  or  tenninate 
in  the  formation  of  parenchymatous  salpingitis. 


362  Oojjhoro-Saljiiiniitls  without  Cystic  Tumor. 


CHAPTER  XXVII. 


OOPHORO-SALPINGITIS   WITHOUT   CYSTIC 
TUMOR. 

Pathogeny;  JEtiology. — Does  there  exist  a  primary  ovaritis,  an 
initial  and  original  lesion  in  connection  with  menstrual  disorders, 
with  sexual  excesses,  independent  of  any  infection  or  antecedent 
lesion  of  the  uterus  and  tubes?  Dalche  and  Prochownick  have 
recently  maintained  this  view,  hut  without  sufficient  proof.  It 
appears  doubtful  to  me.  I  do  not  believe  that  there  exists  a  positive 
example  of  ovaritis,  properly  so-called,  without  a  previous  endo- 
metritis and  salpingitis.  In  truth,  both  of  these  stages  may  have 
been  definitely  marked  without  leaving  permanent  anatomical  traces, 
but  they  can  be  reconstructed  fi-om  the  study  af  the  antecedents. 

I  shall  employ,  then,  by  preference,  the  term  tubo-ovaritis,  or 
oophoro-salpingitis,  and  if  I  happen  to  abbreviate  by  saying  sal- 
pingitis or  ovaritis  it  will  be  understood  that  these  terms  signify  a 
mixed  lesion.  Inflammations  of  the  uterus,  without  contradictions, 
are  the  great  source  of  inflammations  of  the  appendages.  It  is  by 
continuity  of  tissue,  from  place  to  place,  by  the  mucosa,  that  the 
infection  ordinarily  occurs  whether  it  relates  to  a  specific  inflam- 
mation or  to  any  other.  Schi'oeder  admits  this.  In  a  recent  dis- 
cussion at  the  Societe  de  Chirugie,  this  opinion  was  expressed  by 
the  majority.  Champiomiiere,  nearly  smgle-handed,  defended  propa- 
gation by  the  lymphatics  in  all  cases,  a  method  of  propagation 
which  he  first  admitted  for  puerperal  accidents  exclusively.  He 
relies,  in  particular,  upon  the  relative  integrity  of  the  uterine  ex- 
tremity of  the  tubes,  in  cases  where  the  external  two-thirds  is 
excessively  affected.  To  this  it  may  be  replied  that  there  is  not  an 
histological  indemnity,  but  a  simple  apparent  indemnity,  for  the 
tube,  almost  healthy  to  the  naked  eye,  is,  at  this  place,  markedly 
inflamed  luider  the  microscope.  Besides,  analogous  interruptions 
are  found  in  the  series  of  the  lesions  proj)agated  fi-om  the  bladder 
to  the  ureters  and  to  the  kidneys.  However,  the  role  of  the  lym- 
phatics can  not  be  neglected.  The  extreme  frequency  of  adhesions 
uniting  the  fundus  uteri  to  the  appendages  is  well  known.  Now, 
these  adhesions  are,  as  Poirier  has  sho\\ii,  almost  entirely  composed 
of  lymphatics,  bringing  the  subendothelial  net  work  of  the  uterus  into 
communication  with  the  lymphatics  of  the  appendages.  It  is  not 
improbable  that  these  adhesions  may  be  the  result  of  the  action  of 
a  previous  metritis  on  the  deep  lymphatics,  of  which  the  subendo- 


Oophoro- Salpingitis  without  Cystic  Tumor.  363 

tlielial  plexus  is  only  a  prolongation.  This  inflammation  of  the 
uterus  may  follow  this  route  to  the  tubes  and  ovaries,  especially  if 
a  new  pathological  influence  gives  it  a  fresh  impulse. 

However  this  may  be,  if  a  catarrhal  endometritis  lasts  some  time, 
the  tubes  become  more  or  less  affected,  hut  the  symptoms  on  this 
side  are  too  shght  to  call  the  attention  of  the  physician  to  the  epi- 
phenomenon.  In  intense  metritis  with  slight  salpingitis  the  latter 
is  not  noticed,  and  only  the  metritis  is  treated.  On  the  other  hand, 
in  a  marked  salpingitis,  a  slight  metritis,  the  source  of  the  tubal 
affection,  may  easily  pass  unnoticed.  The  very  great  frequency  of 
endometritis  explains  that  of  the  lesions  of  the  tubes,  inasmuch  as 
a  passing  metritis  is  generally  succeeded  by  a  permanent  lesion  of 
the  tubes.  Winekel,  out  of  five  hundred  and  seventy -five  female 
cadavers,  has  found  more  or  less  marked  lesions  of  the  tubes  in  one 
hundred  and  eighty-two  cases.  Lewers,  out  of  one  hundred  autop- 
sies at  the  London  hospital,  found  the  lesions  of  hydrosalpinx, 
pyosalpinx  or  hematosalpinx  in  seventeen  cases.  Gallabin  from 
1883  to  1886  found  in  Guy's  hospital,  twelve  cases  out  of  three 
hundred  and  two  autopsies,  or  four  to  one  hundred.  Lawson  Tait 
remarks  that  this  hospital  draws  its  patients  from  a  better  class 
than  the  London  hospital  and  blennorrhagic  and  puerperal  infection 
is  less  frequent. 

Blennorrhagic  infection  is  the  most  usual  cause  of  inflammation 
of  the  tubes,  if  we  may  believe  Noeggerath.  He  attributSs  a  special 
importance  to  inoculations  of  blennorrhagic  virus,  wliich  might  be 
called  attenuated,  that  is  the  result  of  an  old  male  blennorrhoea, 
where  the  remains  of  an  acute  infection  are  reputed  both  incurable 
and  inoffensive.  A  considerable  number  of  young  married  women 
are  thus  infected,  and  it  is  believed  that  the  supposed  influences  of 
early  intercourse  are  responsible.  A  slight  endometritis  and  an 
intense  catarrhal  metritis  are  often  produced  in  this  way.  Abortion 
results,  aggravatmg  the  pre-existing  disease  and  leaving  the  woman 
a  chronic  invalid  and  sterile. 

The  blennorrhagic  infection  sometimes  gives  rise  to  much  more 
serious  evils,  leading  at  once  to  the  formation  of  pus  in  the 
tubes,  which  may  be  encysted,  or  be  propagated  to  the  pelvis.  This 
is  the  form  that  Bermutz  has  especially  described,  and  that  I  have 
frequently  observed  at  Lourcine.  I  saw,  in  one  case,  a  true  blennor- 
rhagic pyasmia  occur  suddenly  with  multiple  foci,  and  independent 
of  disseminated  suppuration  in  the  subperitonasal  cellular  tissue  and 
in  the  thickness  of  the  mesentery.  There  existed  an  intense  vagi- 
nitis with  pyosalpmgitis.  The  gonococcus  of  Meisser  cannot  always 
be  found,  even  when  the  blennorrhagic  origin  of  the  affection  is  evi- 
dent.   It  has  been  clearly  demonstrated,  however,  a  number  of  times. 

Puerperal  infection,  which  succeeds  to  an  accouchement  and 
especially  to  abortion,  occurring  in  septic  conditions,  belongs  in  the 


3()4  OojyIioro-SdIji'uKiitix  wUhout  Cijutir  Tumor. 

first  rauk  as  a  cause  of  intiammation  of  the  appendages.  In  women 
affected  with  blemiorrhagia,  at  the  time  of  parturition,  there  is,  it 
seems,  a  mixed  infection  puerpero-blennorrhagia,  which  explains 
why  metrosalpingitis  is  so  frequent  in  such  cases.  It  is  especiallj' 
in  metritis,  following  abortion  with  retention  of  the  debris  of  the 
placenta,  that  secondary  lesions  of  the  tubes  are  to  be  feared,  and 
this  is  not  one  of  the  smallest  reasons  why  we  should  then  prefer  an 
energetic  interference  (blunt  curette  and  irrigations)  to  expectation 
or  to  the  timid  interference  which  some  authors  advise.  The  cures 
they  obtain  are  often  only  such  in  appearance.  The  woman  who 
carries  neurotic  debris  in  the  uterine  cavity  for  some  days  is  almost 
surely  condemned  to  a  metrosalpingitis. 

Infection  by  exploration  and  ht/  ohstetrico-surgical  interference. — The 
sound  has  made  numerous  victims,  and  the  same  is  true  of  discision 
of  the  cervix,  before  the  antiseptic  period.  Even  to-day  it  must  be 
remembered  that  to  expect  intrauterine  exploration  to  be  without 
danger  not  only  must  the  finger  and  the  instrument  be  aseptic,  but 
the  cavity  of  the  cer^dx  must  also  be  put  in  the  same  condition  by 
successive  douches.  The  presence  of  a  cause  of  infection  in  the 
cervix  affords  a  complete  explanation  of  certain  eases  of  metritis 
and  salpingitis  that  are  without  other  appreciable  tetiology  than  an 
obstruction  to  the  evacuation  of  the  cervical  secretions  by  a  devi- 
ation or  a  stenosis. 

When  the  normal  drauiage  of  the  mucus  charged  with  nrtually 
pathogenetic  microbes  occurs  with  difdculty,  there  is  a  reflux  into 
the  uterine  cavity,  often  after  a  very  marked  dilatation  of  the  cervix. 
Can  an  auto-infcction  be  thus  produced?  It  is  certauily  not  to  be 
doubted  that  inflammation  of  the  uterus  and  of  the  appendages  is 
very  frequent  in  these  conditions. 

Tubercular  salpingitis  may  occur  with  other  disorders  of  the 
genital  apparatus  of  the  same  nature  and  be  lost  in  the  midst  of  other 
lesions.  Bi;t  in  very  many  cases  it  has  been  observed  as  an  isolated 
lesion.  Is  it  autoinfection  or  heteroiufection  (by  the  introduction 
of  tuberculous  spermatozoa  into  the  genital  passage)  to  which  tu- 
bercular salpingitis  must  be  attributed?  The  place  of  entrance  of 
Koch's  bacillus  appears  to  have  ])een  tlu'ough  the  genital  passage 
in  many  observations  (Conheim,  Yerneuil).  However,  there  are  a 
number  of  cases  of  tuberculosis  of  the  appendages  in  virguis  which 
are  not  thus  explained.  In  these  cases  it  is  probable  that  an  ordi- 
nary auto-infection,  septic,  has  first  been  induced  by  a  stenosis  of 
the  cervix,  and  that  the  bacillus,  introduced  into  the  circulation  by 
the  lungs  or  digestive  tract,  is  fixed  on  the  inflamed  tubes  at  the 
place  of  least  resistance.  This  hypothesis  is  in  accord  with  the  ■s'iews 
which  tend  to  prevail  in  general  pathology  on  what  is  called  pre- 
tubercular  inflammation. 


Oophorosalpingitis  tvithout  Cystic  Tumor.  365 

Malformations  and  congenital  atrophies  of  the  tubes  also  consti- 
tute a  true  morbid  predisposition,  that  Lawson  Tait  and  Freund 
have  perhaps  exaggerated. 

I  only  remind  the  reader  of  the  rare  influence  of  the  eruptive 
fevers,  notably  that  of  scarlatina  or  that  of  variola,  so  weU.  estab- 
lished by  Tait,  and  that  of  the  very  problematic  contagion  of  genital 
papillomata,  noted  by  Alban  Doran,  to  explain  a  papillomatous 
salpingitis,  the  exact  nature  of  which  remains  undecided. 

The  evidences  of  syphilitic  salpingitis  that  have  been  cited  are 
open  to  criticism.  New  observations  on  this  subject  are  necessary. 
Pathological  anatomy. — 1.  Lesions  of  the  tubes. — These  lesions 
are  more  constant  and  more  characteristic  than  those  of  the  ovaries, 
at  least  in  the  acute  forms.  Their  mucous  surface  is,  in  fact,  more 
vulnerable  than  the  serosa  that  surrounds  the  ovary. 

The  comprehensive  term  catarrhal  salpingitis  has  been  much 
abused.  If  the  published  observations  are  examined,  it  will  be 
seen  that  it  has  been  applied  to  the  most  diverse  pathological  con- 
ditions. All  the  inflammations  of  the  tubes,  that  are  not  purulent, 
have  been  placed  in  this  class,  from  a  simple  slight  endosalpingitis, 
accompanying  an  ephemeral  endometritis  that  has  been  sponta- 
neously cured,  to  the  hypertropliic  pachysalpingitis  with  luxuriant 
vegetations  of  the  mucous  folds  and  excessive  thickness  of  the  walls. 
It  is  this  confusion  which  makes  it  so  difficult  to  estimate  accurately 
the  therapeutic  merit  of  numerous  operative  measures  from  the 
results  recently  published.  When  it  is  understood  that  a  tube  only 
slightly  increased  in  volume,  and  more  or  less  inflamed,  merits,  in 
the  opinion  of  some  surgeons,  the  accusation  of  salpingitis  and 
condemnation  to  a  removal,  we  hesitate  to  indorse  the  value  of  a 
brilliant  series  of  operations  which  only  demonstrates,  in  fact,  the 
incontestable  simplicity  and  actual  innocuity  of  castration  with 
antiseptic  precautions.  That  it  may  be  otherwise,  it  will  be  indis- 
pensable to  have  every  observation  on  extirpation  of  the  appendages 
accompanied  by  a  brief  but  i^recise  description  of  the  lesion,  in 
place  of  justification  by  a  vague  epithet. 

I  also  'believe  that  it  is  necessary  to  carefully  distinguish  acute 
catarrhal  salpingitis  from  chronic  parenchymatous  salpingitis  with 
acute  exacerbation,  what  has  sometimes  been  confounded  with  vege- 
tating catarrhal  salpingitis.  What  renders  this  confusion  easy  is 
that  many  women  are  operated  on  when  the  chronic  lesion  has 
undergone  an  acute  aggravation  modifying  its  exact  chronology. 

Finally,  acute  purulent  non-cystic  salpingitis  must  not  be  con- 
founded with  a  purulent  cystic  salpingitis,  or  pyosalpinx,  wliich  is 
a  result,  if  the  former  is  prolonged,  but  is  also  as  distinct  as  pyelo- 
nephrosis  is  from  pyonephritis. 
In  acute  catarrhal  salpingitis  an  hypertrophy  is  first  noted.     The 


366 


Oop]io7-o-S(dphviitls  ivithout  Cystic  Tumor. 


organ  is  swollen  in  the  form  of  a  cylinder  from  the  size  of  the  little 
linger  to  that  of  the  thumb,  as  much  from  infiltration  of  its  wall  as 
from  that  of  the  subserous  tissue.  Being  connected  by  its  inferior 
border  to  the  wing  of  the  large  ligament  the  tube  is  indented, 
moniliform,  and  curved.  The  pavilion  is  sometimes  stretched  and 
turgescent,  more  frequently  folds  on  itself  in  the  form  of  a  folded 
star.  Transparent  false  membranes,  generally  tliin,  soft,  lamellar, 
or  filamentous,  allow  the  bloodvessels  to  be  seen  that  sometimes 
connect  the  tubes  to  the  ovary  and  to  the  contiguous  parts.  The 
surface  of  the  tube  is  pinkish,  the  pavilion  of  a  brighter  color.  On 
section,  the  cavity  is  seen  tilled  with  the  normal  folds  in  an  hypertro- 
phic condition,  of  a  reddish-gray  or  silver-gray  color,  giving  them 
a  vegetating  appearance.   Mucus  sometimes  oozes  from  the  surface. 


207. — Acute  purulent  salpingitis 


The  histological  examination  shows  that  these  lesions  are  es- 
pecially marked  in  the  mucosa.  The  folds  are  covered  with  lateral 
granulations  of  new  formation ;  in  place  of  being  thin  and  sharply 
defined,  the  folds  are  thick  and  blunt.  Many  of  them  anastomose 
in  arcades  at  their  internal  extremity,  giving  the  section  a  reticu- 
lated appearance.  The  framework  of  these  vegetations  is  cellulo- 
vascular,  infiltrated  with  embryonic  cells.  A  layer  of  ciliated  cells 
still  covers  them  in  some  portions.  The  lesions  are  relatively  but 
slightly  marked  in  the  fibro-muscular  tunic.  Only  an  hj^ierplasia 
of  its  elements  is  found. 

Acute  purulent  non-cystic  salpingitis  is  more  rarely  observed 


Oophorosalpingitis  without  Cystic  Tumor. 


367 


than  the  encysted  form,  or  pyosalpinx,  in  which  it  surely  terminates 
if  it  lasts  some  time,  and  if  the  pus  does  not  escape  easily  by  the 
uterine  orifice.  According  to  Freund,  this  unfavorable  condition  is 
especially  associated  with  an  incomplete  development  of  the  oviduct. 


Fig.  208. — Acute  purulent  salpingitis  (12  diameters).    //,  vegetations; 
/,  wall  of  the  tube;  v,  vessel  (Cornil). 

He  claims  that  two  classes  of  tubes  cdn  be  recognized  in  the  healthy 
woman ;  the  first  almost  straight  and  of  normal  caliber,  the  second 
curved  and  of  a  caliber  narrowed  in  some  parts,  a  vestige  of  an 
infantile  state.  In  the  first  class,  the  tubal  affections  are  of  rapid 
evolution  and  may  be  spontaneously  cured.  In  the  second,  the 
suppurative  inflammation  necessarily  terminates  in  the  formation 
of  encysted  collections — in  consequence  of  atresia  of  the  oviduct. 
This  malformation  will  be  suspected  from  the  delicate  complexion 
of  the  patient,  dysmenorrhcea,  and  the  retarded  appearance  of  the 
menses.  It  is  possible  that  this  condition  should  be  taken  into 
consideration,  but  more  frequently  it  is  probable  that  an  intense 
inflammation  may  be  sufiicient  to  produce,  outside  the  protective 
occlusion  of  the  abdominal  orifice,  a  swelling  and  an  infiltration  of 
the  walls,  so  that  the  caliber  of  the  tube  becomes  obliterated  or 
ceases  to  be  permeable  on  the  uterine  side.  This  often  happens  in 
blennorrhagia. 


368  Oophoro-SaljiiiKjiti^  iritliout  Cystic  Tumor. 

However,  the  trausfoimatiou  into  pyosalpiiix  is  always  preceded 
by  a  phase  of  acute  purulent  salpingitis,  proHuent ;  that  is,  \\'ith 
permeability  of  the  ostium  uterinum  and  free  exit  for  the  purulent 
secretion.  If  operation  has  been  performed,  at  this  moment  all 
the  external  signs  of  an  intense  inflammation  of  the  tube  are 
observed :  swelling,  flexuous  curvature,  and  even  a  nodular  ap- 
pearance of  the  oviduct.  The  fimbris  of  the  pavilion  are  agglu- 
tinated so  as  to  close  the  abdominal  orifice.  If  the  organ  is  incised, 
pus  is  found  in  the  cavity.  The  cavity  sometimes  has  a  moniliform 
appearance.  The  pus,  creamy,  like  that  of  recent  formation,  may 
empty  into  the  uterus  through  the  uterine  orifice,  wliile  the  abdomi- 
nal opening  is  obliterated  by  the  fusion  of  the  fimbriae  of  the  tubes. 
The  microscope  shows,  in  transverse  sections,  very  thick  folds 
covered  with  anastomosing  granulations,  forming  a  system  of 
principal  and  of  secondary  reduplications  whose  union  produces 
irregular  cavities  resembling  glands.  This  thickening  is  due  to  the 
abundance  of  migratory  cells  which  infiltrate  the  connective  tissue. 
The  ciliated  cells  have  almost  disappeared  and  the  epithelial  cells 
are  deformed,  becoming  cubiform  or  flattened,  preserving  their 
form  only  in  the  sinuses  which  separate  the  folds.  Here  the  culs- 
de-sac  are  lined  with  short  cylindrical  epithelium,  producing  a 
resemblance  to  glands.  The  whole  thickness  of  the  wall  is  also  in- 
filtrated with  migratory  round  cells  and  the  vessels  are  large  and 
dilated  (Cornil). 

When  purulent  salpingitis  is  not  transformed  into  pyosalpinx,  it 
may  undergo  a  spontaneous  cure,  as  has  been  proven  by  clinical 
observation.  This  retrogressive  process  is  rare,  and  during  this 
time  the  patient  is  exposed  to  the  reaijpearance  of  the  acute  con- 
dition. When  it  is  accomphshed,  the  resolution  occurs  by  mdu- 
ration,  as  the  older  writers  s^y ;  that  is,  with  the  formation  of 
embryonic  connective  tissue,  which  terminates  in  hypertrophy  of 
the  organ,  at  least  temporarily — in  pachy-salpingitis. 

Cornil  (Fig.  209)  has  shown  a  good  specimen  of  purulent  sal- 
pingitis, seemingly  in  the  process  of  evolution.  The  primarily 
isolated  vegetations  reunite  and  constitute  an  embryonic  tissue 
wliich  at  first  appears  homogenous.  From  this  results  a  layer  of 
liew  tissue,  which  separates  the  wall  of  the  tube  and  narrows  its 
caliber  by  presenting  in  the  cavity  small  projections,  consisting  of 
embryonic  tissue  or  gi-anulations. 

In  clu'onic  parenchymatous  salpmgitis,  it  is  the  rule  to  find  both 
tubes  attacked,  w'hile  the  very  acute  and  slight  lesions  may  be  uni- 
lateral. This  peculiarity  is  the  origin  of  Tait's  radical  precept,  to 
always  perform  ablation  of  the  two  sides,  the  second  being  almost 
certainly  destined  to  be  attacked  after  the  first.  Marked  lesions 
affecting  the  ovary,  periovaritis,  sclerosis,  are  also  frequently 
observed. 


Oophoro- Salpingitis  without  Cystic  Tumor. 


369 


In  the  majority  of  cases  the  appendages  are  fixed  to  the  pelvic 
wall  or  to  Douglas'  cul-de-sac  by  very  strong  adhesions.  These 
adhesions  may  even  be  so  firm  that  the  ovary  and  the  tubes  can 
only  be  released  by  an  actual  laceration.  The  thickened  tube 
sometimes  becomes  as  hard  as  a  cord.  The  lesions  that  occur,  in 
place  of  being  almost  entirely  confined  to  the  mucosa,  as  in  the  pre- 
ceding forms,  are  propagated  to  all  the  thickness  of  the  walls.  ■■  It 
may  even  be  said  that  the  alterations  of  the  middle  coat  of  the 
parenchyma,  are  here  of  the  greatest  importance.  Chronic  sal- 
pingitis, even  much  more  than  chronic  metritis,  is  then  essentially 
parenchymatous.  On  section,  a  great  thickness  of  all  the  walls  is 
seen.  The  mucosa  has  a  slate  color.  The  external  orifice  is  always 
obliterated ;  sometimes  it  adheres  to  the  ovary  qiiite  loosely.  The 
uterine  orifice,  on  the  contrary,  is  most  frequently  open.  This 
lesion  has  also  been  called  pachy-salpingitis,  or  interstitial  sal- 
pingitis, from  the  considerable  proliferation  of  connective  tissue 
that  the  microscope  shows.  It  is  the  analogue  of  chronic  epididy- 
mitis with  sclerosis  of  the  cord. 


Fig.  209. — Acute  purulent  salpingitis  (12  diameters).  /,  connective  tissue  of  the 
wall;  z/,  vessel;  i5  ^,  embryonic  tissue  with  cavities ;  a  a  ffl,  lined  with  epithelial  cells 
and  with  more  narrow  openings;  ff,  also  containing  epithelial  cells;  d.  cavities  of  the 
same  nature  near  the  wall  (Cornil). 


Two  anatomical  varieties  of  this  lesion  may  be  distinguished, 
corresponding  exactly  to  what  is  also  observed  in  parenchymatous 


370  Oophoro-Salpingitls  ivithout  Cystic  Tumor. 

metritis.  In  the  first  variety  there  is  chronic  hypertrophic  sal- 
pingitis. The  tube,  of  a  size  from  that  of  the  httle  finger  to  that  of 
the  index,  is  of  a  violaceous  color  and  of  fleshy  consistency.  If  it 
is  incised,  there  is  found  a  thick  shell,  either  of  hypertrophied 
muscular  tissue,  or  connective  tissue  of  new  formation  and,  witliin 
this,  filling  the  interior  of  the  canal  of  the  tube,  a  pulpy  substance 
of  a  brilliant  and  silvery  aspect,  formed  by  the  vegetating  mucosa 
with  its  epithelium  very  much  altered.  The  abdominal  extremity 
is  obliterated,  the  uterine  extremity  is  simply  narrowed.  The  con- 
dition seems  to  be  the  result  of  an  old  purulent  salpingitis  that  the 
permeability  of  the  ostium  uterinum  has  prevented  from  becoming 
cystic.  In  my  observations,  as  in  those  of  Kaltenbach  and  Schauta, 
there  were  positive  blenuorrhagic  antecedents.  These  authors 
attribute  some  influence,  perhaps  exaggerated,  to  the  muscular 
hypertrophy  in  the  production  of  tubal  colic.  This  may  be  observed 
when  the  hypertrophy  of  the  tubal  waU  is  purely  of  the  connective 
tissue  form,  and  these  painful  attacks  appear  to  be  due  to  the  com- 
pression of  the  nervous  filaments,  to  a  perineuritis  wliich  has  been 
well  demonstrated  in  Sawinoff's  preparations. 

Another  variety  of  chronic  salpingitis  can  be  called  atrophic. 
The  cellular  infiltration  of  the  tubal  wall,  in  place  of  giving  origin 
to  a  persistent  product,  to  permanent  proliferation,  as  in  the  pre- 
ceding case,  produces  retraction  of  the  tissues  by  resorption.  It  is 
probably  only  a  more  advanced  stage  of  hypertrophic  pachy-salpin- 
gitis,  passing  to  the  state  of  cirrhosis  of  the  tube.  The  muscular 
structure  disappears  before  the  fibrous  tissue,  the  whole  organ  is 
retracted,  and,  in  the  most  extreme  degree,  is  transformed  into  a 
hard  and  impermeable  cord.  Boldt  has  well  described  these  lesions. 
In  several  cases  he  has  seen  the  lumen  of  the  tube  completely 
effaced  by  the  agglutination  of  the  walls.  He  notes  the  complete 
destruction  of  the  epithelium  that  is  then  produced,  as  in  cirrhosis 
of  the  liver  and  kidney.  Orthman  gives  the  name  of  follicular  sal- 
pingitis to  an  anatomical  lesion  which  does  not  merit  designation 
as  a  distinct  variety.  It  relates  to  cystic  caA-ities  in  the  wall,  which 
give  it  an  areolar  appearance.  This  pseudo  glandular  formation  is 
common  to  all  forms  of  inflammation  of  the  tube  (Figs.  208  and  211). 
In  all  the  varieties  I  have  described  the  tube  may  continue  to  form 
a  canal  open  at  its  two  extremities,  and  the  permealiility  of  the 
ostium  uterinum  will  allow  evacuation  of  the  mucus  as  it  is  fomied. 
From  this  proceeds  the  absence  of  ampullar  or  cystic  dilatation. 

II.  Lesions  of  the  ovaries. — The  ovary,  though  often  unattacked  in 
catarrhal  salpingitis,  is  frequently  involved  in  the  lesions  of  acute 
purulent  salpingitis  and  in  those  of  the  chronic  form.  Then  it  is 
often  deviated,  fixed  by  adhesions  in  the  Douglas'  cul-de-sac  or  to 
the  sides  of  the  pelvis.  It  is  not  impossible  to  have  suppuration 
independent   of  the   tube,   but   such  cases  are  exceedingly  rare. 


Oophorosalpingitis  without  Cystic  Tumor.  371 

Usually  the  OTariaii  lesions  are  rather  less  advanced  than  those  of 
the  tubes.  Exceptionally  they  exist  alone  as  a  chronic,  sclero-eystic 
ovaritis.  The  initial  alterations  of  acute  ovaritis  are  imperfectly 
known.  The  advanced  lesions  that  are  most  frequently  met  are  : 
1.  False  membranes  (to  which  I  shall  not  return) ;  2.  Micro-cystic 
degeneration;  3.  Sclerosis;  4.  Suppuration. 

Micro-cystic  degeneration.. — This  name,  or  that  of  clironic  follicular 
oophoritis,  has  been  given  to  a  lesion  characterized  by  the  presence 
of  numerous  small  cavities,  varying  from  the  size  of  a  millet  seed 
to  that  of  a  pea,  strewn  over  the  surface  of  the  ovary.  This  form 
has  often  been  described  in  cases  where  castration  has  been  per- 
formed simply  for  painful  symptoms.  These  cavities  contain  a 
serous,  clear  liquid,  sometimes  clots.  Some  authors  see  in  this 
condition  undoubted  pathological  alteration.  Others,  in  greater 
number,  consider  this  state  as  having  nothing  morbid.  It  is,  in 
fact,  very  probable  that  these  small  follicular  cysts  have,  by  them- 
selves, no  inflammatory  significance,  and  they  are  met  where  no 
symptom  exists.  But  they  may,  however,  play  a  certain  role  in 
creating  by  their  multiplicity  a  true  vulnerability  of  the  organ,  and, 
in  fact,  interstitial  sclerosis  is  often  seen  in  ovaries  thus  attacked. 


Fig.  2IO.— Ovarian  hypertrophy. 

Sclerosis  of  the  ovary,  or  insterstitial  ovaritis,  is  the  lesion  wliich 
corresponds  to  the  generality  of  the  subacute  or  chronic  inflam- 
mations. In  its  early  period  it  is  not  incompatible  with  ovulation. 
But  if  it  passes  certain  limits,  the  follicles  are  compressed  and 
strangulated  (Slavjansky).  The  compression  of  the  nerve  filaments, 
produced  in  the  same  manner  when  the  ovary  is  atrophied  by 
sclerosis,  has  been  considered  as  the  principal  cause  of  the  nervous 
symptoms  for  which  Battey's  operation  is  performed.  Most  fre- 
quently the  immediate  cause  of  the  sclerosis  appears  to  be  a  local- 
ized peritonitis,  a  perioophoritis,  and  the  alteration  progresses 
fi'om  the  periphery  to  the  centre.  This  perioophoritis  may  be  want- 
ing, however,  and  the  point  of  departure  of  the  proliferation  may 
be  in  the  interstitial  tissue  of  the  ovary.  It  is  in  these  cases  that  the 
ovarian  hypertrophy  may  acquire  the  size  of  a  goose  egg  and  present 
on  its  surface  a  mammilated  aspect,  as  if  cirrhotic  (Fig.  210). 


372 


Oophoro-Salp'tiHiitis  icithout  Cystic  Tumor. 


Flo.  211. — Chronic  hypertrophic  salpingitis  (lo  diameters).  I,  sclerosed  wall;  2, 
thick  and  fused  villi:  3,  pseudo-glandular  formations;  4,  bloodvessel;  5,  accessory 
canal  of  the  tube. 

Jones  has  found  on  an  ovary  of  this  kind,  the  size  of  an  egg  and 
granular  on  its  surface,  an  interestmg  lesion  that  I  have  alreadj' 
noted  in  speaking  of  chi-onic  metretis— lymphatic  ectasia.  The 
lacunae  were  filled  with  an  almost  homogeneous  lymph  with  some 
lymph  corpuscles.  An  elastic  coat  and  a  thick  endothelium  were 
clearly  distmguished.     Sclerosis  of  the  ovary  usually  coincides  with 


Oophoro-Salpinc/itis  without  Cystic  Tumor.  373 

micro-cystic  degeneration  and  thus  is  found  constituting  a  mixed  state 
sclero-cystic ovaritis,  much  more  frequent  than  the  isolated  lesions. 

Suppuration  of  the  ovary  most  frequently  coexists  with  that  of 
the  tubes.  Both  are  fused  to  form  the  wall  of  a  purulent  pocket, 
the  pyosalpinx  is  then  in  reality  a  pyo-oophoro-salpinx.  In  some 
cases  the  tube  may  present  a  condition  of  chronic  interstitial  endo- 
metritis while  the  ovary  alone  may  be  transformed  into  a  purulent 
cavity,  or  present  cu-cumscribed  abscesses.  In  similar  cases  the 
inflammation  is  often  propa-gated  by  adhesion  and  infection  coming 
from  the  tube  which  has  been  the  first  attacked,  and  in  which,  with- 
out doubt,  after  evacuation  of  its  contents  into  the  uterus,  the 
inflammation  has  assumed  the  clu'onic  form,  while  the  purulent 
material  remained  imprisoned  in  the  ovary.  At  other  times,  these 
organs  have  remained  apart  from  each  other,  an  indirect  ovarian 
infection  through  the  lymphatics  must  be  admitted.  However  this 
may  be,  it  is  probable  that  the  formation  of  an  abscess  in  the  ovary 
is  often  favored  by  a  pre-existing  small  cyst,  follicular  cyst,  or  a 
cyst  of  the  corpus  luteum,  or  simply  by  micro-cystic  degeneration. 
When  tliis  predisposition  does  not  exist,  the  acute  inflammation 
gives  place  more  frequently  to  perioophoritis. 

Symjjtojns. — It  is  rare  to  observe  an  acute  salpingitis  outside  of  a 
similar  inflammation  of  the  uterus.  It  is  therefore  difficult  to  dis- 
tinguish in  a  given  case  the  symptoms  which  proceed  from  the  one 
from  those  that  belong  to  the  other  affection.  The  uterine  syndrome 
occupies  equally  in  the  two  diseases  the  first  rank  in  the  symp- 
tomatic description.  I  will  note,  however,  the  special  points  which 
indicate  invasion  of  the  tubes  and  ovaries  by  the  inflammation. 

The  pain  offers  the  character  of  pseudo  neuralgic  attacks  seated 
in  the  region  of  the  appendages  and  in  the  lumbar  region.  There 
are  radiations,  above,  toward  the  epigastrium ;  below,  toward  the 
thighs.  Sometimes,  but  not  in  all  cases,  they  occur  as  true  colic, 
that  has  been  called  tubal  colic,  and  we  may  be  misled  by  the 
evacuation  of  little  muco-pus,  at  the  close  of  the  paroxysm,  pro- 
ceeding less  from  the  tubes  than  from  the  uterus,  which  has  been 
incited  to  contraction  by  the  attacks  of  pain.  Pressure  in  the 
region  of  the  appendages  is  painful,  both  by  abdominal  palpation 
and  by  vaginal  examination.  If  the  inflamed  ovary  is  compressed 
between  the  two  hands,  an  exquisite  pain  is  awakened  (Gaillard), 
especially  on  the  left,  for  the  left  side  is  most  frequently  attacked. 
The  pain  in  the  lumbar  region  is  often  attended  with  gastralgia 
and  vomiting.  It  is  most  frequently  manifested  at  the  time  of  the 
catamenial  molimen.  Exceptionally  it  is  observed  that  the  menses 
coincide  with  a  period  of  calm  and  that  the  crises  are  produced  in 
the  interval.  Menorrhagia  is  an  almost  constant  symptom,  but 
there  are  often  long  periods  of  amenorrhoea,  or  of  great  irregularity 
of  menstruation. 


374  Oophom-Salpbuiith  without  Cystic  Tumor. 

Examination  of  the  inflamed  organs  in  tubo-ovaritis  is  very  diffi- 
cult on  account  of  the  pain  that  is  occasioned.  Patients  should  lie 
ansstbetized  if  tbere  is  doubt  and  if  immediate  interference  is  to 
be  decided  on.  I  camiot  be  too  emphatic  in  criticizing  a  systematic 
neglect  of  this  valuable  auxiliary  and  against  the  substitution  of  a 
single  element  of  diagnosis,  localized  pam,  for  the  exploration  of 
the  anatomical  condition  of  the  parts.  Such  a  neglect  leads  to  a 
too  frequent  resort  to  exploratory  laparotomy.  Palpation  of  the 
appendages  should  conform  to  the  excellent  precepts  Sehultz  has 
laid  down.  For  examination  of  the  right  side,  the  index  and 
middle  fingers  are  introduced  into  the  vagina,  the  left  hand  being 
placed  on  the  abdomen;  for  the  left  ovary  the  order  is  reversed. 
The  patient  is  placed  on  her  back,  the  knees  uplifted  and  the  thighs 
rotated  outward ;  the  psoas  muscles  are  then  tense.  The  internal 
border  of  these  muscles  is  followed  to  the  superior  strait,  then 
directing  the  exploration  a  little  more  inward  toward  the  uterine 
cornu.  Here  a  small,  ovoid  tumor  is  encountered,  normally  the 
size  of  an  almond,  that  is  included  between  the  two  hands.  A 
lesion  of  the  appendages  can  scarcely  escape  an  exploration  made 
in  accordance  with  these  rules  under  an  anassthetic. 

Noeggerath  has  proposed  to  make  exploration  of  the  tubes  by 
vesico-rectal  examination,  and  he  has  thus  made  out  certain  details 
that  it  would  evidently  be  impossible  to  recognize  otherwise.  But 
this  method  should  be  employed  only  as  a  last  resort.  Although 
Hegar  affirms  that  he  can  recognize  by  touch  micro-cystic  degener- 
ation of  the  ovary  and  catarrhal  salpingitis,  it  must  be  admitted 
that  so  great  a  delicacy  of  touch  will  be  the  possession  of  but  very 
few  surgeons.  However,  in  acute  salpingitis  one  A\"ill  often  perceive 
the  lesions  more  easily  than  would  be  expected,  because  there  is 
added  a  peripheral  oedema  which  doubtless  trebles  the  volume  of 
the  inflamed  tube.  In  chi-onic  salpingitis  the  tube  will  be  felt  as  a 
resisting  cord,  immobilized  by  adhesions  to  the  sides  of  the  pelvis. 
When  with  these  physical  signs  and  the  manifest  antecedents  of 
metritis  there  is  a  fixed  pain  localized  in  the  region  of  the  ap- 
pendages, presenting  the  characters  that  I  have  indicated,  a  sal- 
pingitis can  be  diagnosed  ^\•ith  certainty.  Pus  will  be  suspected  if 
the  point  of  departure  is  a  recent  blennorrhagia  or  the  revival  of  a 
post-ahortum  septic  infection. 

Diagnosis. — The  pain  of  the  salpingitis  must  not  be  confounded 
with  that  of  ovarian  neuralgia.  The  latter  is  generally  seated  on 
the  left  but  may  be  bilateral.  Charcot  has  shown  that  it  is  often 
accompanied  with  anaesthesia  of  the  same  side  and  hystero-epilepti- 
form  attacks.  The  peculiar  hysterical  character  of  this  pain 
differentiates  it  from  that  of  salpingitis.  Lumbo-abdominal  neu- 
ralgia, which  may  exist  alone,  and  which  so  often  accompanies 
metritis,  has  its  distinctive  sign,  its  special  seat,  in  the  abdominal 


Oophoro-Saljnngitis  uithout  Ci,stic  Tumor.  375 

wall,  where  it  is  awakened  by  superficial  pressure,  especially  on 
the  points  where  the  nerves  emerge.  The  pressiire  on  the  ap- 
pendages may  then  appear  painful,  because  of  the  sensitiveness  of 
the  abdommal  wall.  Repetition  of  the  two  modes  of  exploration 
successively  should  clear  up  the  diagnosis. 

Inflammation  of  the  uterus  will  be  recognized  by  its  special 
symptoms,  which  I  need  not  repeat.  It  is  rare  that  there  do  not 
exist  at  least  some  vestiges  of  metritis  in  patients  affected  with 
tubal  inflammation.  Even  when  it  preponderates,  metritis  is 
frequently  accompanied  with  a  slight  degree  of  ascending  salpingits, 
too  slight  to  give  rise  to  physical  signs  appreciable  by  the  touch,  or 
to  merit  a  place  in  the  nomenclature  of  the  affection,  or  to  modifj' 
the  treatment,  but  sufficient,  however,  to  increase  the  sensitiveness 
of  the  appendages. 

Is  it  possible  by  physical  examination  to  determine,  in  oophoro- 
salpingitis, what  belongs  to  the  tube  and  what  to  the  ovary '?  It 
must  be  admitted  that  this  is  usually  impossible,  and  happily  is 
not  necessary  in  deciding  the  question  of  operation.  Sclero-cystic 
disease  of  the  ovary  may  exist  without  notable  tubal  lesions,  but  the' 
affections  of  these  two  organs  are  rarely  dissociated.  The  ovary  is  , 
very  frequently  even  united  to  the  tube  by  adhesions  so  that  the 
tumor  is  mixed  tubo-ovarian.  There  exist  some  cases,  however, 
where  by  bimanual  exploration  it  is  possible  to  differentiate  between 
the  thick,  cord-like  form  of  the  tube  and  the  oblong  tumor  formed 
by  the  ovary.  The  latter  is  much  more  mobile  and  more  detached 
from  the  uterus.  It  often  demands  for  its  recognition  a  long  search, 
and  the  introduction  of  two  fingers  deej)  into  the  posterior  and 
lateral  culs-de-sac.  In  some  cases  bimanual  palpation,  with  rectal 
touch,  wiU  be  preferable.  Besides  these  characters  of  form  and 
mobility,  the  ovary  presents,  when  it  is  inflamed,  an  exquisite  sen- 
sitiveness, which  causes  the  patient  to  cry  out  and  to  shrink  on  the 
slightest  contact  of  the  exploring  finger.  Finally,  when  the  ovaritis 
predominates,  especially  on  both  sides,  the  dysmenorrhcea  is  more 
intense  and  sudden  augmentations  are  noticed  in  the  tumor  at  the 
menstrual  periods,  either  from  a  simple  congestion  or  from  a  san- 
guineous extravasatio  i  into  the  micro-cystic  cavities  at  that  time. 

Cystic  salpingitis  and  perisalpingitis  will  be  recognized  from 
the  volume,  the  character  and  the  connections  of  the  tumor  that 
they  produce.  However,  it  should  be  remarked  that  at  intervals  of 
a  Jew  days  there  may  be  recognized,  by  turns,  either  the  elongated 
tumor  of  acute  or  chronic  salpingitis,  or  the  romided  and  more  or 
less  dift'use  swelling  of  perisalpingitis,  induced  by  an  acute  exacer- 
bation of  short  duration. 

Progress  and  Prognosis. — Inflammation  of  the  mucous  membrane 
of  the  tubes  is  infinitely  more  rebellious  than  that  of  the  tubes. 
When  the  septic  element  is  intrenched  in  the  multiple  folds  of 


376  Oophoro-Salp'tiKjitiH  without  CtjHth-  Tumor. 

the  external  tliird  of  the  organ,  it  is  inaccessible  to  direct  thera- 
peutic measures,  ami  if  resolution  takes  place  it  can  justly  be  said 
that  it  is  spontaneous  and  by  local  destruction  of  the  microbes. 
It  is  kno^\^l  that  this  fortunate  result  is  not  impossible  in  other 
regions.  It  may  take  place  here  too,  especially  if  judicious  treat- 
ment be  dii-ected  to  the  uterine  mucosa.  May  this  cure  be  accom- 
plished with  restitutio  ad  intefjiiim?  Assuredly,  but  in  exceedingly 
rare  cases.  After  the  cure  of  an  acute  inflammation  the  tube  often 
remains  more  or  less  altered.  Anatomical  facts  also  show  the 
possibility  of  a  cure  ^itli  atrophy  remaining.  On  the  other  hand, 
in  the  clinic,  the  persistence  of  the  morbid  symptoms,  ^vhen  the  ap- 
pendages are  once  attacked,  proves  how  rebeUious  the  disease  is 
and  what  lingering  traces  it  leaves  behind. 

The  special  gravity  of  acute  or  ehi'onic  salpingitis  Lies  in  the 
tendency  to  attacks  of  perisalpingitis  (pelvi-peritonitisj  which  are 
always  imminent.  Fatigue  or  errors  of  iliet  may  rekindle  the  in- 
flammation. Lawson  Tait  believes  that  in  some  cases  a  few  dr-ops 
of  muco-pus  have  fallen  into  the  peritonaeum  and  produced  irritation. 
Though  this  theory  may  be  a  little  crude,  there  ^\iU  then  be  found 
on  examination  a  peri-peripheral  doughiness  caused  by  infiltration 
or  by  acute  oedema  of  the  subpeiitonseal  cellular  tissue.  In  most 
cases  resolution  then  takes  place  with  the  aid  of  quiet  and  judicious 
management,  until  a  new  attack.  These  attacks  may  oecm-  suc- 
cessively, during  months  and  even  years,  and  are  remarkable  each 
time  for  the  suddenness  of  the  appearance  and  disappearance  of 
the  inflammatory  tumors  foimd  in  the  culs-de-sac.  These  tumors, 
being  formed  by  small  circumscribed  nuclei,  give  the  sensation  of 
glandular  masses,  and,  in  conseqiience,  have  been  attributed  by 
many  authors  to  inflamed  glands.  From  this  have  arisen  the 
terms  periuterine  adenitis,  adeno-lymi^haugitis.  Glands  do  not 
exist  in  this  situation,  so  it  is  not  adenitis ;  but  this  acute  cedema 
is  produced,  without  doubt,  around  the  lymphatic  trunks  and  is 
consequently  a  perilymphaugitis.  It  is  observed  above  the  vaginal 
culs-de-sac,  at  the  sides  of  the  cervix,  in  a  point  where  Poirier  has 
described  convolutions  of  the  lymphatic  vessels  which  pass  from 
the  ceiTix  to  the  ihac  glands. 

Sterility  is  not  an  absolute  consequence  of  salpingitis,  as  the  in- 
flammation may  be  cured  without  obliteration  of  the  tubes.  How- 
ever, when  a  clu-onic  salpuagitis  has  occluded  both  tubes,  fecun- 
dation is  impossible,  and  this  is,  without  doubt,  the  cause  of 
sterility  in  the  majority  of  prostitutes. 

Treatment. — Though  a  woman  suffers  persistently  in  the  region  of 
the  appendages,  tliis  is  not  sufiicient,  as  some  operators  would  have 
it,  to  authorize  laparotomy,  even  though  confined  to  exploratory 
incision.  After  a  certain  period  of  surgical  excess  we  have  again 
come  to  have  a  greater  respect  for  the  conservation  of  the  repro- 


Oophoro-Sidpimjltis  u-'Uhout  Cystic  Tumor.  377 

ductive  fiinction  to  strive  for  c-tire  in  place  of  extirpation.  The 
treatment  of  catarrhal  tubo-ovaritis  is  associated,  with  that  of  me- 
tritis, just  as  that  of  ascending  pyelo-nepluitis  corresponds  with, 
that  of  the  cystitis  which  produces  it.  Absohrte  rest,  slight  pur- 
gatives, rigid  antisepsis  of  the  vagina,  hot  and  prolonged  vaginal 
injections  are  the  first  measures  to  be  prescribed.  To  these  may 
be  added,  if  required,  bleeding,  either  by  scarification  of  the  cervix 
or  by  leeches  over  the  iliac  fosste,  an  excellent  means  of  quieting 
the  acute  pains,  when  there  are  no  contra-indications.  The  appli- 
cation of  a  succession  of  small  blisters  with  morpliine  cliloro- hydrate' 
(one  centigramme)  on  the  denuded  surface,  repeated  cauterizations 
in  the  iliac  region,  prolonged  warm  baths,  enemas  of  laudanum,  of 
valerian,  of  cliloral,  are  the  best  means  of  quieting  the  pain. 

We  may  hope  to  cure  the  salpingitis  at  the  same  time  with  the 
endometritis,  provided  the  lesions  have  not  had  time  to  become  in- 
veterate. Uterine  curetting,  followed  with  repeated  injections  of 
tincture  of  iodine,  as  described  under  metritis,  has  yielded  excellent 
results  in  my  hands,  in  the  early  stage  of  salpingitis.  Trelat  has 
obtained  similar  success  by  curetting  and  injections  of  creosoted 
glycerine.  It  is  also  to  the  antiseptic  treatment  of  the  metritis, 
rather  than  to  the  mechanical  action  of  dilatation,  that  we  must 
refer  the  cures  published  by  Walton,  Gottschalk  and  Doleris. 

Should  curetting  be  performed  when  the  salpingitis  is  accom- 
panied with  an  acute  perisalpingitis,  characterized  by  painful 
nuclei  in  the  vaginal  culs-de-sac  ?  I  think  not.  It  is  better  to  wait 
until  it  disappears  under  the  influence  of  rest  and  antiphlogistics. 
It  subsides  very  rapidly  when  it  does  not  depend  on  an  encysted 
tubal  tumor.  Such  an  attack  permits  an  important  positive  diag- 
nosis. In  fact,  to  recommend  forced  dilatation  and  curetting  as  a 
curative  measure  in  perimetritic  exudation,  according  to  Walton, 
of  Brussels,  and  Poullet,  of  Lyons,  is  to  formulate  a  dangerous  rule, 
because  it  is  based  on  the  supposition  that  one  would  never  make 
a  mistake  in  diagnosis.  Certainly  treatment  by  curetting  has,  in 
some  cases,  cured  or  relieved  serous  perisalpingitis  together  with. 
the  salpingitis,  but  this  treatment  may,  in  analogous  cases,  kill 
patients  affected  with  unrecognized  pyosalpinx  by  causing  rupture 
of  the  cyst.  In  view  of  this  danger  and  the  frequent  presence  of 
great  uncertainty  of  diagnosis,  is  it  not  better  to  wait,  before 
curetting  the  uterus,  until  the  acute  trouble  has  disappeared  and  to 
make  certain  that  there  has  not  been  a  concealed  accumulation  of 
pus  ?  Apropos  of  indirect  treatment,  I  may  allude  to  the  supposed 
efficacy  of  electricity  in  some  forms  of  salpingitis.  I  believe  that 
it  has  been  considerably  exaggerated.  It  appears  certain  that  we 
should  not  use  puncture  in  encysted  accumulation  in  the  tubes,  as- 
the  fluidifying  electrode  is  as  dangerous  as  the  trocar.  If  there  is 
a  hydro-  or  a  hiematosalpinx  it  may  also  cause  suppuration.     If 


S78  Oophoro-SalpuKjlth  iflthoitt  Cystic  Tumor. 

there  is  a  pyosalpinx  we  are  exposed,  by  this  incomplete  opening, 
not  only  to  a  fistula  but  still  more  to  septic  accidents.  Vaginal 
galvano-puncture  has  also  the  disadvantage,  if  it  does  not  penetrate 
the  collection,  of  causing  adhesions,  wliich  remain  a  source  of 
painful  dragging  and  an  obstacle  to  a  rapid  operation.  With  these 
esceptious,  I  recognize  the  utility  of  the  intrauterine  galvano-caustic, 
which,  by  modifjiug  the  endometrium,  may  cure  a  catarrhal  sal- 
pingitis at  the  same  time.  But  I  believe  it  is  more  comphcated 
and  less  sure  than  curetting  and  mtrauterine  injections.  In  very 
nervous  women  the  Faradic  current,  applied  mth  an  intrauterine 
bipolar  electrode,  has  given  relief.  But  it  is  always  necessary  to 
proceed  ■^^ith  care  and  to  fear  in  every  case  a  hidden  collection  of 
pus,  as  electrization  of  the  uterine  cavity  has  caused  the  rupture  of 
a  pyosalpinx. 

Massage  has  been  strongly  advised  of  late  years  for  all  inflam- 
mations of  the  uterus  and  appendages,  and  like  all  new  measures, 
has  excited  an  undue  amount  of  enthusiasm.  It  is  far  from  being 
inoffensive.  I  believe  it  should  be  reserved  solely  for  cases  of 
ehi'ouic  salpingitis,  without  any  suspicion  of  an  encysted  collection. 
In  eases  of  acute  inflammation  massage  does  more  harm  than  good. 
However,  I  advise  its  use  for  cases  where  there  are  the  remains  of 
pre^-ious  inflammations,  adhesions,  cicatricial  deviations,  causing 
pains,  a  condition  for  which  laparotomy  has  been  too  often  per- 
formed. 

If  aU  other  therapeutic  measures  fail,  after  a  suflicient  trial,  re- 
com-se  to  a  radical  operation,  oophoro-salpingotomy,  is  justifiable. 
There  should  be  no  hesitation  when  the  intensity  of  the  symptoms 
leads  to  a  suspicion  of  a  purulent  salpingitis  that  is  rapidly  be- 
coming a  menace  to  life.  Here  operation  should  not  be  proscribed, 
although  one  should  be  more  conservative  in  chronic,  non-purulent 
tubo-ovaritis.  These  lesions,  in  fact,  while  not  directly  endangering 
life,  make  it  quite  insupportable  by  the  almost  incessant  pains  and 
the  effects  on  the  general  health.  But  it  is  only  after  six  months, 
or  less,  of  patient  treatment,  by  the  means  I  have  indicated,  that 
the  surgeon  would  be  justified  in  advising  castration  for  a  non- 
puiTilent  salpingitis. 

Ablation  of  the  appendages,  save  in  exceptional  cases,  is  a  benign 
operation.  It  comprehends  in  reaUty  two  distinct  operations  :  1. 
The  rupture  of  the  peripheral  adhesions  with  replacement  of  the 
uterus;  generally  retroversion  or  retroflexion.  2.  Ablation  of  the 
tube  and  of  the  ovary  as  near  the  uterus  as  possible. 

The  abdominal  incision  should  Ije  the  rule.  The  vaginal  incision 
does  not  appear  to  offer  any  gi-eat  advantages  here,  and  presents 
some  grave  disadvantages  when  complications  occur  durmg  the 
operation.     It  is  always  necessary  to  remove  the  ovary  on  the  side 


Oophoro-Salpingitis  without  Cystic  Tumor.  379 

from  which  the  tube  has  been'  exth'pated,  even  though  it  does  not 
appear  diseased. 

In  certain  cases  coukl  we  not  confine  ourselves  to  the  first  part 
of  the  operation — separation  of  the  adhesions  and  liberation  and 
replacement  of  the  uterus  and  its  appendages  ?  Hadra  was  the 
first  to  suggest  that  the  morbid  symptoms  for  winch  the  healthy- 
ovaries  have  been  so  often  removed,  notably  the  sharp  abdominal 
pains,  could  be  cured  by  simply  breaking  up  the  adhesions.  He 
then  proposed,  whenever  laparotomy  was  performed,  to  carefully 
examine  all  the  organs  for  adhesions,  cautiously  slipping  the  hand 
between  the  intestinal  loops,  under  the  omentum,  above.  He  is 
satisfied  with  this  procedure  if  the  ajiijendages  are  normal,  and  only 
removes  them  if  they  are  actually  diseased.  Polk  goes  further  in 
this  direction.  Having  seen  the  disease  completely  cured  after 
removing  only  one  tube,  although  the  one  left  in  place  presented 
manifest  symptoms  of  inflammation,  he  proposes  to  simply  express 
the  muco-purulent  contents  of  the  diseased  tubes,  to  make  the 
peritoneal  toilet,  and  to  close  the  abdomen,  after  having  performed 
hysterorrhaphy,  if  necessary.  Munde  rallies  to  the  support  of  this 
procedure  and  proposes  to  add  catheterism  of  the  tubes  and  irri- 
gation from  the  abdominal  extremity.  Howitz  has  also  replaced 
castration  in  some  cases  with  the  liberation  of  adhesions. 

He  cites  a  remarkable  observation  when  the  phenomena  of  clu'onic 
salpingitis  have  thus  been  cured  without  salpingotomy,  although 
the  right  tube  appeared  inflamed  and  swollen.  He  especially 
insists  on  the  pathological  role  of  adhesion  of  the  omentum  to  the 
symphysis  pubis.  Tins  relative  conservatism  is  also  manifested 
among  other  authors.  J.  L.  Championniere  and  Terrillon  have 
pronounced  in  favor  of  this  direction  in  a  few  cases.  Martin  has 
not  confined  himself  to  the  destruction  of  adhesions ;  he  opens  the 
obhterated  extremity  of  the  tube  and  has  even  reconstructed  a 
pavilion. 

It  is  impossible  to  judge  these  recent  procedures.  Perhaps  it  is 
necessary  to  fear  passing  from  one  extreme  into  the  other,  and  after 
having  been  too  prompt  to  extirpate,  we  should  not  be  in  too  much 
haste  to  substitute  ingenious  operations  of  a  deceptive  or  a  doubtful 
efficacy.  However,  the  fortunate  results  of  simple  hysterorrhaphy, 
after  rupture  of  adhesions,  in  cases  where  there  manifestly  existed 
salpingitis  and  perisalpingitis,  show  that  the  tubes  and  ovaries 
have  certainly  been  sacrificed  in  cases  when  they  could  have  been 
preserved.  The  replacement  of  the  uterus,  the  liberation  of  the 
appendages,  and  the  antiseptic  cleansing  of  the  pelvic  cavity,  which 
is  a  necessary  consequence  of  the  operation,  will  surely  diminish  the 
number  of  oophoro-salpingotomies.  We  could  without  doubt 
reserve  extirpation  of  the  appendages  for  three  classes  of  cases : 


380  Cystic  Oophow-SalpiiKjith. 

1.  Ovaritis  and  salpingitis  where  the  presence  of  pus  and  its 
consequences  are  feared.  2.  Painful  sclero-cystic  ovaritis.  3. 
Chi'ouic  parenchymatous  and  cystic  (serous  or  haematic)  salpingitis, 
where,  in  spite  of  the  only  slightly-menacing  progress  of  the  lesions, 
it  is  necessary  to  operate  for  the  relief  of  menorrhagic  and  dysmeu- 
orrhceic  accidents  and  nervous  reflexes. 

The  ablation  of  the  mflanied  appendages,  containing  only  a 
small  quantity  of  mucus  or  of  muco-pus,  without  transformation 
into  pyosalpinx,  is,  we  can  say,  a  benigii  operation.  Conservatism 
is  not  demanded  so  much  by  the  gravity  of  the  operation  as  by  the 
consequent  stei'ility. 


CHAPTER  XXVIII. 


CYSTIC   OOPHORO-SALPINGITIS. 

It  is  convenient  to  place  m  the  first  rank,  among  the  cystic 
dilatations  of  the  tube,  that  which  is  due  to  the  accumulation  of 
pus.  It  seems  to  have  been  proven,  in  fact,  that  pyosalpinx  is 
often  transformed  into  a  serous  and  sometimes  into  an  hiematic 
cyst.  Wlien,  without  doubt,  by  spontaneous  destruction  of  the 
germs,  the  inflammatory  j)rocess  is  arrested,  an  abscess  of  the  tube 
may,  like  a  cold  abscess,  change  into  a  serous  form  by  a  sort  of 
clarification  of  the  pus,  its  sohd  elements  being  deposited  on  the 
wall  while  the  sei'ous  part  increases  in  quantity.  Such  appears  to 
be  the  origin  of  the  great  majority  of  eases  of  hydrosalpinx. 
Finally,  the  rupture  of  the  new  vessels  in  the  walls  of  a  pyosalpinx 
of  long  standing  has  sometimes  filled  the  sac  with  blood. 

Pathological  anatomy. — Pyosalpinx,  or  purulent  cj'st  of  the  tube, 
is  a  consequence  of  purulent  salpingitis,  in  paiiicular  from  bleii- 
norrhagic  or  from  pueiiseral  infection,  the  latter  relating  principally 
to  post-ahmium  cases.  Lawson  Tait  and  Freund  have  attached 
gTeat  importance  to  an  incomplete  development,  to  an  mfantile 
state  of  the  oviduct,  which  predisposes  to  obliteration  and  to  cystic 
degeneration.  After  its  external  extremity  is  closed  l)y  agglutination, 
and  by  an  intussusception  of  the  fimbriiie  of  the  pa^'ilion,  the  tulie 
becomes  dilated  in  its  external  two-thirds,  or  in  nearly  its  whole 
length.  More  frequently  there  remains  about  one  to  two  centimeters 
of  the  tube  near  the  cornu  of  the  uterus  that  preserves  almost  a 
normal  size,  but  presents  an  increased  firmness.  The  paviHon  is 
BOmetimes  adherent  to  the  ovary,  wliich  is  more  or  less  eom]iletely 


Cystic  Oophoro-Salpinciitis.  381 

fused  with  the  cyst.  It  is  rare  to  find  the  paviUon  free  and  intact 
beyond  the  limited  pus  sac,  because  of  an  obhteration  internal  to  it 
near  the  uterus.  False  membranes  are  disseminated  around  the 
tubes  and  ovaries,  fixing  them  most  frequently  posteriorly  in 
Douglas'  cul-de-sac.  The  uterus  is,  in  consequence,  usually  de^•i- 
ated  from  its  normal  position.  The  left  tube  is  almost  constantly 
larger  than  the  right. 

The  cysts  are  variable  in  size.  They  have  been  found  as  large  as 
a  foetal  head.  But  ordinarily  they  do  not  exceed  the  volume  of  a 
small  pear,  and  frequently  take  a  similar  form.  Often  they  are 
curved  on  themselves  in  the  shape  of  a  French  horn  (Fig.  213). 
The  color  is  a  yellowish  white.  The  thickness  of  the  sac  is  variable. 
There  frequently  exists  a  weak  point  which  corresponds  to  the 
posterior  adhesions,  so  that  there  is  often  difficulty  in  avoiding 
rupture  at  this  place  during  extirpation.  The  pus  is  usually 
creamy  and  yellow,  presenting  a  fetid  odor  when  the  adhesions  with 
the  rectum  are  intimate.  A  cyst  of  the  broad  ligament,  or  of  the 
ovary  situated  immediately  under  the  inflamed  tube,  has  been 
seen  to  suppurate  and  communicate  with  it.  I  have  met  one 
example  of  the  first  variety. 

With  the  microscope,  the  internal  surface  is  found  covered  with 
ramifying  vegetations,  analogous  to  those  of  acute  catarrhal  salpin- 
gitis, but  two  or  three  times  thicker,  owing  to  the  infinitely  greater 
infiltration  of  the  stroma  with  round  cells.  They  are  covered  by  a 
simple  layer  of  cylindrical  cells  which  has  persisted  in  the  fundus 
of  the  cavities  which  separate  them.  The  deep  layers  of  the  mucosa 
are  rich  m  fusiform  cells.  Nearer  the  surface  exists  a  zone,  or 
cellular  infiltration,  so  abundant  that  it  gives  the  appearance  of 
granulation  tissue.  The  walls  of  the  tube,  in  the  part  not  dilated, 
which  appear  relatively  normal  to  the  naked  eye,  are  also  infiltrated 
■with  embryonic  cells.  The  dilatation  of  the  vessels  is  especially 
noticeable. 

In  pyosalpinx  there  may  exist  a  certain  permeability  of  the  inferior 
end  of  the  tube.  It  has  been  said  that  in  this  variety — profluent — the 
walls  are  thicker.  This  appears  to  be  due  to  the  fact  that  they  are 
not  distended  to  excess.  It  has  also  been  claimed  that  the  liyi^er- 
trophy  of  the  muscular  fibers  could,  then,  assure  evacuation  of  the 
sac.  This  is  very  doubtful.  It  would  rather  be  due  to  over-dis- 
tension. Pyosalpinx  may  coincide  with  uterine  tumors,  fibrous  and 
cancerous. 

Cold  abscess  of  the  tube,  or  tubercular  pyosalpinx,  is  distinguished 
with  difficulty  when  there  do  not  exist  similar  lesions  of  the  uterus 
and  ovaries  at  the  same  time.  There  may  exist,  however,  on  the 
contiguous  peritonaeum,  characteristic  tuberculous  granulations. 
With  regard  to  caseous  masses  in  the  tubes,  they  may  be  produced 
by  a  simple  inspissation  of  pus,  and  this  phymatoid  appearance,  to 


382 


Cystic  Ouphoro-Salpiiujltis. 


,.  ; 


-rrrt 


^ !  M  WW 


Fig.  212. — Micro-cystic  degeneration  of  the  ovary. 


Fig.  213. — Sclero-cyslic  degeneration  of  the  ovary. 

which  the  older  ^yl•itel•s  attributed  so  much  value,  is  of  little  impor- 
tance The  microscope  alone  can  solve  the  question  by  showing  the 
special  cellular  structure  of  the  tubercular  follicle,  with  its  nuclear 
zones  gi-ouped  arouud  the  giant  ceUs,  and  especially  Koch's  bacillus. 
Hegar  and  Orthmaun  have  recognized  this,  but,  like  the  gonococcus 
of  Neisser  in  blenuorrhagia,  it  may  be  wanting  (having  disappeared) 
without  our  bemg  able  to  affirm  that  the  lesion  is  not  specific. 

Sometimes  the  ovary  makes  an  iutegi-al  part  of  the  sac  by  fusion 
with  it.  h.i  other  times  small  disseminated  abscesses  proceed, 
without  doubt,  from  the  suppuration  of  folhcular  cysts.  Finally,  it 
may  contain  a  large  purulent  ca\-ity. 

Hydrosalpin.r,  or  tubal  dropsy,  is,  in  an  anatomical  point  of  \-iew, 
the  oldest  kno\\Ti  lesion  of  the  tube.     But  it  cannot  be  doubted  that 


Cystic  Oophorosalpingitis.  383 

it  has  often  been  confounded  with  certain  tubo-ovaiian  cysts,  where 
the  tube  is  not  dilated  itself,  but  only  elongated,  hypertrophied  and 
adherent  to  an  ovarian  cyst  communicating  with  it.  Thus  are 
explained  the  colossal  dimensions  the  older  writers,  and  even  modern 


Fig.  214. — Pyosalpinx.     1,  dilated  part  of  the  tube  formed  by  its  external  portion ; 
2,  median  portion;  3,  section  of  the  tube  near  the  uterine  extremity. 


Fig.  215  Pyosalpinx  (Wyder 


ones  (Peaslee),  attributed  to  hydrosalpinx.  It  is  doubtful  if  these 
tumors  can  exceed  the  size  of  a  foetal  head.  Most  frequently  they 
attain  only  that  of  a  small  pear.  The  appearance  is  smooth,  the 
color  bluish-white,  the  walls  are  generally  thin,  transparent  in 
portions,  papyraceous.  There  are  generally  a  few  false,  superficial 
membranes,  or  they  are  thin  and  distended,  for  the  hydropsia  of 
the  tubes  corresponds  to  an  extinct  inflammation  of  very  old  date. 
Froriep  divides  hydropsia  tubse  into  two  varieties,  aperta  and  occhisa, 
according  as  there  is  an  opening  or  an  occlusion  at  the  internal 
extremity. 


384  Cystic  0(ij)li(irii-S(dpuifiitis. 

Hiematosalpinx  should  be  distinguisbed  from  the  small  liiemor- 
rhages  or  bsematomas  of  the  tube  which  distend  the  simply  in- 
tiamed  walls  of  the  o^•iduct.  These  effusions  of  blood,  susceptible 
of  resorption,  constitute  a  symptom  rather  than  a  disease.  Hiema- 
tocele  of  the  tube,  or  true  hsematosali^inx,  comprises  both  an 
extensive  alteration  of  the  waUs,  which  have  assumed  a  cystic  char- 
acter and  a  modification  of  the  sanguineous  liquid,  similar  to  that 
which  it  undergoes  in  hsematocele.  It  is,  in  a  word,  a  stable  lesion 
in  place  of  a  transitory  pathological  symptom,  hke  the  simple 
effusion  of  blood  in  an  inflamed  organ.  But  the  preceding  dis- 
tinction not  having  been  made  by  other  authors,  I  shall  conform  to 
the  common  usage.  If  we  leave  to  one  side  cases  of  retention  of 
blood  by  atresia  of  the  genital  passages,  which  should  be  treated 
under  maKormations,  there  remain  two  chief  varieties  of  hsemato- 
salpiux  :  1 .  The  first,  and  ^^ithout  doubt  the  most  frequent,  is  apoplexy 
of  the  tube,  following  incidentally  in  the  course  of  a  catarrhal  in- 
flammation, or  even  in  the  course  of  a  menstruation  that  has  been 
disturbed  by  excessive  fatigue,  or  by  a  chill  in  a  neurotic  or  a 
plethoric  indi^■idual.  It  is  possible  that  the  symptoms  attributed 
by  some  authors  to  congestion  of  the  uterus,  to  pelvic  congestion, 
have  no  other  origin.  The  lesion  does  not  generally  persist,  the 
clot  is  absorbed  and  the  symptoms  may  cease  by  degi-ees  unless 
they  have  been  grafted,  as  is  so  often  the  case,  on  the  symptoms  of 
a  chi-onic  parenchjTnatous  salpingitis.  2.  The  second  variety  of 
hsematosalpinx,  the  only  one  wliich  possesses  a  true  anatomical 
individuahty,  is  especially  characterized  by  the  presence  of  a  sac 
analogous  to  that  of  pyosalpinx.  For  the  development  of  this  sac, 
I  believe  it  is  necessary  to  assume  either  a  tubal  pregnancy, 
arrested  in  its  development  by  early  death  and  absorption  of  the 
embryo,  or  a  previous  pyosalpinx  that  has  obliterated  the  tube  and 
thickened  the  walls  in  proportion  as  it  dilates.  The  haemorrhage 
following  in  a  pathological  canity,  from  a  surface  incapable  of 
resorption,  becomes  definitive.  Sometimes  this  transformation  is 
made  directly,  sometimes  there  is  an  intermediate  stage  of  hydro- 
salpinx. In  the  last  case  the  fluid  is  clearer  and  the  wall  thinner. 
On  the  other  hand,  it  may  happen  that  a  hiematosalpinx  suppurates 
secondarily.  The  infection  then  occurs  rather  by  the  lymphatics 
than  fi'om  the  uterine  cavity,  ■nith  which  all  communication  is 
closed. 

The  size  of  these  sacs  does  not  generally  exceed  that  of  a  pear. 
However,  Lawson  Tait  has  cited  one  which  rose  beyond  the  um- 
bilicus and  contained  several  litres.  It  appears  to  me  diflicult  not 
to  believe  that  he  had  at  the  same  time  an  encysted  intraperitona?al 
haematocele  connected  ^vith  the  h.Bmatosalpinx.  Hiematosalpinx  is 
often  seen  to  coincide  with  fibroids.  It  is  not  to  the  pressure  of 
these  tumors  on  the  ostiian  uter'niinii  that  it  should  be  attributed. 


Cijstic  Oophiiro-SaliniHiith 


385 


but  rather  to  a  lifemorrhagic  metrosalpingitis  which  accompanies 
the  development  of  the  myomata. 


Fig.  2i6. — Suppurated  hematosalpinx.  A  grooved  sound,  a,  passes  through  an 
orifice  which  communicated  with  the  rectum ;  6,  a  ligature  placed  on  the  uterine 
extremity.     The  small  reniform  body  represents  a  clot  or  an  embryo  (?). 

The  sac  of  an  hsematosalpinx  is  thick  in  places,  thin  in  others. 
Hypertrophy  of  the  muscular  fibers  may  be  met  as  in  pyosalpinx. 
The  communication  ■with  the  uterus  may  persist.  With  regard  to 
the  contents,  the  blood  may  be  syrupy  and  of  a  chocolate  color 
(principally  M'here  the  lesion  is  due  to  menstrual  retention  from 
malformation) ;  more  frequently  the  liquid  is  a  mixture  of  blood 
and  serum,  or  of  blood  and  pus.  Clots  may  form  layers  on  the 
wall  or  small,  free,  fibrinous  masses  (Fig.  216).  Histological  study 
of  the  sac  shows  an  irritative  process,  less  marked  than  in  pyo- 
salpinx. However,  there  is  still  an  unusual  riclmess  of  the  mucosa 
in  fusiform  cells  wliich,  in  some  folds,  seem  to  elevate  the  deep 
layer  perpendicularly.  The  summit  of  these  folds  is  generally 
deprived  of  epithelium.  The  intervals  which  separate  them  may 
preserve  a  rich  capillary  plexus,  gorged  with  blood,  that  can  be 
followed  to  the  surface  of  the  mucosa.  In  some  places,  small  pa- 
renchymatous hpemorrhages  hide  the  framework  of  the  tissues  (Fig. 
217). 

Syvqttoms. — It  may  appear  singular,  a  priori,  that  one   should 


386 


Cystic  Oophoro-Saljiiiifiltls. 


attempt  to  present  simultaneously  the  clinical  picture  of  purulent, 
of  serous,  and  of  sanguineous  collections.  In  fact,  except  from 
clinical  observation,  we  would  hardly  believe  that  a  woman  could 
carry  in  the  abdomen  one  or  two  sacs  tilled  with  pus  mthout  pre- 
senting grave  symptoms,  or  at  least  appearing  to  suffer.  Between 
the  initial  period  of  formation  and  the  ultimate  period  of  inflam- 
mation of  the  eontiguoiis  tissue  and  efforts  of  spontaneous  evacu- 
ation, pyosalpiux  passes  thi-ough  a  torpid  and  latent  phase,  in  which 
the  economy,  protected  by  the  perfect  encystment  of  the  septic 
liquid,  seems  to  tolerate  its  presence.  The  rational  signs  are 
exactly  similiar,  then,  to  those  of  a  chronic  salpingitis,  and  the 
physical  signs  do  not  differ  from  those  of  hydro-  or  hematosalpinx. 


Fig.  217. — Hcematosalpinx  (Wyder). 

A  picture  including  all  these  conditions  can,  then,  be  presented  by 
merely  adding  certain  characters  which  belong  to  the  acute  period 
of  abscess  of  the  tubes.  This  picture  does  not  diiJer  materially 
from  that  which  I  have  prewusly  traced,  apropos  of  non-cystic 
salpingitis.  There  are  the  same  pains,  the  same  menstrual  troubles 
(amenorrhoea,  dysmenorrhoea,  menorrhagia) ;  however,  the  last  may 
be  wanting  in  exceptional  cases.  In  haematosalpius  Puech  has 
sometimes  noted  an  incessant  flow  of  blood,  occurring  in  very 
small  quantities,  in  the  absence  of  the  menses. 

I  must  also  mention  again  another  symptom,  the  value  of  which 
has  been  much  exaggerated.  I  refer  to  a  sudden  flow,  following  an 
attack  of  colic,  of  a  certain  quantity  of  serous,  sanguineous,  or  puru- 
lent fluid.  This  phenomenon  may  occur  at  regular  intervals — every 
month,  every  six  months,  for  example.  Is  tliis  due  to  the  per- 
sistence of  a  permeable  uterine  orifice  that  relieves  the  excessive 
repletion  of  the  cyst?  Is  it  merely  the  expulsion  of  the  contents 
of  the  inflamed  uterus  from  reflex  contraction  of  its  wall?  If  we 
remember  how  frequent  is  the  obliteration  of  the  cystic  tubes  on  the 
side  of  the  uterine  ca^•ity,  we  will  be  tempted  to  accept  the  latter 


Cystic  Oophorosalpingitis.  387 

explanation.  Tliis  peculiarity  has  been  noted  some  time  since 
by  several  observers.  It  is  the  hydrops  tuba  profluens  of  Froriep. 
Klob,  from  observations  made  on  the  aged,  thinks  that  this  is  an 
explanation  of  the  supposed  return  of  the  menses  after  the  meno- 
pause. Sometimes  by  pressing  on  the  tumor  through  the  abdomen, 
it  can  be  made  to  empty  some  of  its  contents  into  the  vagina. 
This  flow  of  pus,  induced  by  abdominal  pressure,  or  pyometrorrhcea, 
has  been  mentioned  as  a  probable  sign  of  pyosalpinx. 


e 

Fig.  2i8. — Serous  perimetro-salpingitis  (inflammatory  oedema). 

Two  groups  of  symptoms  only  are  specially  characteristic :  the 
pains  which  draw  attention  to  the  appendages  and  the  tumor  found 
at  the  side  of  the  uterus  by  local  examination.  Physical  exami- 
nation should  be  made  by  bimanual  exploration  combined  with 
rectal  touch.  Great  care  must  be  taken,  as  grave  and  even  fatal 
accidents  have  been  caused  by  the  rupture  of  a  pyosalpinx  from 
too  violent  an  exploration.  The  cystic  tumor  of  the  tube  presents 
very  different  characters  according  as  it  is  free  and,  to  a  certain 
extent,  mobile  at  the  side  of  the  uterus,  or  as  it  has  fallen  into 
Douglas'  cul-de-sac  and  become  fixed  by  adhesions.  In  case  the 
tumor  is  free,  the  two  hands  can  seize  a  small  elongated  mass,  in 
the  form  of  a  roll  or  of  a  pear  at  the  side  of  the  uterus,  from  which 
it  is  separated  by  a  groove  formed  by  the  pedicle.  When  the  tumor 
is  bilateral  it  appears  Uke  a  wallet  thrown  over  the  uterus.  Fluctu- 
ation is  rarely  perceived,  but  pain  is  always  developed  if  the  patient 
is  not  anaesthetized.  Sometimes,  while  perceiving  this  sensation  on 
one  side,  all  the  vaginal  cul-de-sac  of  the  other  side,  as  well  as  the 
posterior  cul-de-sac,  is  occupied  by  a  globular  tumor  of  an  elastic 
fluctuating  consistence.  Tliis  is  a  tube  dilated  m  the  form  of  a 
retort  and  lodged  in  Douglas'  cul-de-sac,  lifting  the  uterus  up  and 


388  Cfistir  0«j,h„rn-S,d]>'ni;iitk. 

depressiug  the  rectum.  Generiilly,  tlieu,  the  tumor  is  purulent  and 
is  not  free.  Fcr  some  time  it  presei-ves  its  independence,  but 
finally  becomes  so  agglutinated  to  the  contiguous  parts  that  it  is 
transformed  into  an  abscess  that  cannot  be  enucleated — a  pelvic 
abscess. 

Diagnosis. — Is  it  always  possible  to  distinguish  pyosalpinx  fi-om 
serous  or  haematic  cysts  of  the  tube?  I  have  stated  that  this 
diagnosis  should  always  be  made  with  reserve,  in  view  of  the  extraor- 
dinary tolerance,  durmg  long  periods,  of  a  sac  of  pus  perfectly 
limited.  However,  pyosalpinx  will  be  suspected  if  the  dilatation  of 
the  oviduct  is  produced  after  a  blennorrhagic  or  puerpero-gonov- 
rhoeal  infection,  and  if  the  tumor  is  very  adherent.  When  an 
intermittent  or  a  permanent  fistula  is  observed,  there  is  no  longer 
any  doubt.  The  only  question  that  remams  is  that  of  the  limitation 
of  the  pus ;  of  its  possible  transformation  into  a  pehic  abscess. 
But  in  doubtfiU  cases  tliis  question  can  only  be  settled  by  opening 
the  abdomen.  Hydrosalpinx  and  pyosalpinx  are  nearly  always 
bilateral,  while  hstmatosalpinx  is  more  fi-equently  unilateral.  This 
fact  suggests  that  hematosalpinx  may  not  infrequently  be  due  to  a 
tubal  pregnancy  arrested  in  its  development.  There  may  also  exist 
a  purulent  collection  on  one  side  and  serous  on  the  other.  A  very 
gi-eat  volume  of  a  tubal  tumor,  and  the  absence  of  extensive 
adhesions,  are  ui  favor  of  hydrosalpinx ;  pressure  is  also  less  pain- 
ful than  in  the  purulent  cyst. 

While  the  tumor  is  still  free,  an  encysted  collection  in  the  tube 
may  be  confounded  with  a  cyst  of  the  ovary  and  especially  with  an 
intra-ligameutous  cyst.  The  latter,  however,  is  markedly  lateral 
and  not  usually  separated  from  the  uterus  by  the  interval  which 
coiTBsponds  to  the  pedicle  of  the  tubal  cyst.  The  diagiiosis  of  tubal 
pregnancy  during  the  first  four  months  is  almost  impossible.  The 
majority  of  extirpations  of  fcetal  cysts  have  been  done  in  operations 
performed  for  a  presumed  salpingitis.  The  hypertrophy  of  the 
ntenis,  the  expulsion  of  the  decidua,  are  the  only  probable  signs. 
The  menses  may  not  be  absent. 

Uterine  fibroid  is  one  of  the  diseases  which,  «-ith  the  inexperi- 
enced observer,  is  liable  to  be  mistaken  for  large  cysts  of  the  tube. 
It  is  sometimes  almost  impossible  to  distinguish  between  them  on 
first  exploration.  But  the  careful  use  of  the  uterine  sound  will 
show  the  gi-eat  increase  in  the  depth  of  the  organ  in  fibroids  and  a 
normal  condition  in  the  tultal  affection.  Finally,  fluctuation  is 
always  perceptible  in  hydro-  and  haematosalpinx,  when  they  present 
considerable  volume,  provided  the  patient  is  examined  under  anaes- 
thesia. A  sensation  may  then  be  presented  to  the  touch,  quite 
different  from  that  before  ans^sthesia.  Pyosalpinx,  adherent  and 
projecting  in  Douglas'  cul-de-sac,  often  gives  the  sensation  of 
pasteboard. 


Cystic  Oophoro- Salpingitis.  38b 

In  case  of  doubt  is  it  permissible  to  use  exploratory  puncture  ? 
I  reject  tlus  naeasure  as  dangerous  because  the  tumor  may  be  remote 
from  the  point  of  puncture.  There  is  danger  of  wounding  the 
intestines  and  especially  of  effusion  of  a  septic  liquid  in  the  peri- 
tonaeum; either  primarily,  if  in  spite  of  aspiration,  when  the 
evacuation  has  not  been  complete,  or  secondarily,  when  a  refilling 
of  the  cyst  opens  the  recently  agglutinated  lips  of  the  puncture. 
This  exploration,  which  appears  insignificant,  is  in  reahty  more 
dangerous  than  an  exploratory  incision  made  with  antiseptic  pre- 
cautions. 

The  diagnosis  of  a  large  cyst  of  the  tube  from  a  fibro-cystic  tumor 
of  the  uterus  is  almost  impossible  in  some  cases.  However,  the 
increase  in  the  size  of  the  uterine  cavity,  as  revealed  by  the  sound, 
will  help.  Exploratory  puncture  is  particularly  dangerous  here. 
Pelvic  adenitis,  a  rare  affection,  and  often  of  unknown  origin,  may 
occasion  errors  of  diagnosis.  The  rational  signs  and  the  tumor  it 
causes  have  simiilated  adherent  pyosalpingitis.  Finally,  pregnancy, 
complicated  mth  bilateral  pyosalpinx,  has  been  observed,  the 
nature  of  the  complex  tumor  to  wliich  it  gave  rise  being  recognized 
only  after  exploratory  incision. 

Doleris  has  cited  two  ciirious  cases  of  adherent  enterocele  in 
Douglas'  cul-de-sac,  where  the  pain  and  the  symptoms  furnished 
on  exploration,  simulated  an  inflammatory  tumor  of  the  appendages. 
The  tumor  that  was  found  behind  the  uterus  was  formed  of  mtestmal 
loops  agglutinated  by  inflammatory  products.  These  lesions  did 
not  appear  to  have  resulted  from  disease  of  the  tubes  or  ovaries,  as 
these  organs  were  found  perfectly  healthy.  It  was  then  an  example 
of  pelvi-peritonitis,  probably  of  intestinal  origin,  and  diagnosis  was 
impossible  except  by  laparotomy.  The  ablation  of  the  appendages 
in  these  two  cases  gave  no  relief. 

Progress,  Duration,  Termination,  Prognosis. — It  may  be  affirmed 
that  encysted  collections  in  the  tubes  are  distinct  diseases,  incurable 
by  any  means  except  extirpation.  Women  affected  with  them  are 
exposed  to  acute  attacks  of  perisalpingitis  from  the  least  over- 
exertion. The  progress  of  this  affection  depends  essentially  upon 
renewed  inflammatory  attacks,  as  has  been  observed  in  periuterine 
phlegmon  and  in  pelvi-peritonitis.  In  fact,  lesions  of  the  tubes  are 
even  now  frequently  confounded  with  the  inflammation  to  which 
they  have  given  rise  by  extension.  The  acute  attacks  are  especially 
marked  by  exacerbation  of  the  painful  and  nervous  symptoms  in 
the  non-purulent  tumors.  In  the  latter  there  is  added  a  fever  with 
almost  complete  remissions.  Lawson  Tait  has  attributed  these 
symptoms  to  the  escape  of  some  drops  of  irritating  liquid  from  the 
tubes.  However  that  may  be,  slight  attacks  of  perisalpingitis  are 
incessantly  recurring.  Finally,  there  may  be  complete  rupture. 
Then,  in  case  of  a  serous  or  a  sanguineous  cyst,  the  symptoms  may 


390  Cystic  Ooplioro-SalpiiKjii,  . 

be  comparatively  slight  (as  in  rupture  of  an  ovarian  cyst;.  But  if 
a  pj'osalpiux  ruptures  into  the  peritonaeum,  the  symptoms  are 
abruptly  developed  and  formidable  and  the  cause  is  sometimes 
unrecognized. 

With  regard  to  the  tubal  sac,  if  the  pus  is  continually  produced, 
it  may  become  distended  until  it  comes  in  contact  with  the  con- 
tiguous rectal  and  vaginal  ca^•ities,  becoming  adherent  to  them  and 
emptying  itself  by  a  perforation.  The  orifice  thus  created  tends  to 
remain  as  a  fistula.  This  is  especially  observed  in  case  of  opening 
into  the  rectum,  the  pyosalpinx  having  usually  prolapsed  into 
Douglas'  cul-de-sac.  The  pus  rarely  passes  directly  into  the  vagina 
or  bladder.  Shooting  pains,  tenesmus,  and  slimy  diarrhoea  precede 
the  rectal  opening  (Nonat).  The  symptoms  of  cystitis  indicate 
that  the  pus  cavity  is  about  to  open  into  the  bladder.  A  vesico- 
rectal commuuieatiou  may  be  estabhshed  by  a  double  opening. 
These  fistulae  are  generally  intermittent.  After  a  febrile  attack 
and  premonitory  pains  the  pus  is  suddenly  evacuated ;  a  marked 
and  mstantaneous  relief  ensues.  The  patient,  who  appeared  in 
extremis,  returns  to  Ufe.  She  recovers  more  or  less  good  health 
until  another  attack  sets  in.  Sometimes  such  alternations  last  a 
long  time  without  deep-seated  changes  of  the  general  health.  But, 
ctt  other  times,  the  abscess  takes  an  extremely  septic  character,  the 
temperature  goes  up  to  41-  C,  there  are  violent  chLUs,  delirium, 
and  a  general  appearance  indicating  the  intensity  of  the  infection. 
At  the  end  of  several  attacks  the  patient  becomes  very  weak  and  is 
affected  with  a  sUght  hectic  fever.  An  obstinate  anorexia  is  one  of 
the  most  striking  characters  of  this  morbid  condition.  There  are 
some  women  who  can  tolerate  no  food,  vomit  everything,  and 
literally  die  fi-om  inanition. 

There  exists  another  clinical  type,  where  the  fistula,  peinnanent 
or  intermittent,  induces  no  reaction,  but  gradually  causes  a  general 
decline.  The  opening  of  the  tube,  thus  suppm-ating,  may  lead 
toward  the  ihac  fossa,  giving  rise  to  an  abscess  of  this  region,  or 
forward  into  the  prevesical  tissue,  producing  a  special  form  of 
suppuration  of  Eetzius'  cavity.  These  lesions  will  be  especially 
considered  in  the  following  chapter,  relating  to  pelvic  abscess. 

When  a  relative  ciu-e  is  spontaneously  obtained,  the  plastic 
adhesions,  which  imprison  and  displace  the  uterus  and  appendages, 
constitute  a  permanent  source  of  pain  and  a  constant  menace  to 
the  patient's  health,  owing  to  the  danger  of  uterine  inflammation. 
Still  more,  the  tubes,  even  after  evacuation  of  theii-  contents,  remain 
the  seat  of  interstitial  salpingitis,  at  fii-st  hypertrophic,  then  atro- 
phic, which  perpetuates  the  pain. 

Treatment. — Is  it  possible  to  employ  the  indii-ect  treatment  that 
I  have  advised  for  non-encysted  salpingitis?  Several  authorities 
have  attempted  to  induce  expulsion  of  the  liquid  contents  of  the 


Cystic  Ooplwro-Salpingitis.  891 

tubal  sac  by  opening  its  itterine  oiifice,  by  curetting  and  dilatation 
of  the  uterus.  It  is  sufficient  to  recall  the  pathological  anatomy  of 
such  lesions,  the  complete  and  definite  occlusion  of  the  caliber  of 
the  tube  in  the  immense  majority  of  cases,  to  see  how  vain  is  such 
a  theory.  Cases  of  recoverj'  under  this  treatment  are  cases  of 
perisalpingitis  mistaken  for  a  pyosalpiux.  The  idea  of  evacuating 
the  contents  of  the  tubes  by  catheterism  is  scarcely  worth  mention. 
The  possibility  of  penetrating  into  a  healthy  tube  is  doubtful ;  this 
manoeuver  wiU  be  both  dangerous  and  futile  in  the  case  of  a 
diseased  tube. 

Immediately  on  discovery  of  an  encysted  tumor  of  the  tubes,  its 
extirpation  should  be  performed  at  a  favorable  moment.  Operations 
during  an  acute  attack  should  be  avoided  as  much  as  possible. 
However,  if  the  trouble  presents  a  grave  character,  with  a  tendency 
to  generalized  peritonitis,  especially  if  there  is  reason  to  fear  a 
ruptui'e  of  a  pyosalpinx,  the  abdomen  should  be  opened  at  once. 
This  is  the  only  means  of  saving  the  patient. 

Oophoro-salpingotomy,  performed  in  these  conditions,  offers  in- 
comparably greater  difficulties  than  those  of  an  operation  in 
catarrhal  salpingitis.  Generally  a  larger  incision  is  necessary  than 
for  castration  properly  so-called.  Frequently  the  omentum  is 
adherent  to  the  pubes  and  swoUen  by  an  acute  oedema  that  com- 
pletely changes  its  appearance.  It  should  be  detached  with  the 
finger  covered  with  a  sponge-compress,  and,  if  it  is  much  altered, 
resected  after  catgut  ligature,  in  small  divisions.  The  fingers  will 
immediately  seek  the  location  of  the  fundus,  and  following  the 
cornua  wiU  palpate  the  tubes  and  the  ovaries.  As  soon  as  the  en- 
larged tube  is  recognized,  attempt  is  made  to  pass  around  it, 
attempting  its  detachment  by  insinuating  the  finger  between  it  and 
the  contigTious  organs.  WTien  the  sac  is  very  large  and  its  walls 
very  thin,  it  is  necessary,  for  fear  of  rupture,  to  aspirate  its 
contents,  closing  the  puncture  with  one  or  two  forceps.  If  the 
tumor  is  small,  firm  and  resisting,  it  is  better  to  detach  without 
emptying  it.  When  the  tumor  is  liberated  and  held  only  by  the 
broad  hgament,  this  membranous  pedicle  is  transfixed  -with  the 
blunt  needle  carrjang  a  silk  ligature  which  may  be  tied,  either  with 
the  Tait  knot,  or,  if  the  pedicle  is  too  large,  with  two  crossed  threads 
or  by  a  chain  ligatui'e.  If  it  is  difficult  to  overcome  the  adhesions 
in  Douglas'  cul-de-sac  it  is  preferable  to  begin  by  cutting  the  tube 
at  one  centimeter  from  the  uterus  between  two  ligatures,  at  a  point 
where  it  is  but  little  altered  and  offers  a  true  pedicle.  Thus  the 
adhesions  can  be  detached  from  witliin  outward  in  place  of  pro- 
ceeding from  without  inward.  It  may  be  noted  that  an  attachment 
of  the  vermiform  appendix  to  the  tumor  may  be  mistaken  for  a 
pedicle. 

The  cut  sui'face  of  the  tube  should  be  cauterized  as  an  antiseptic 


392  Cystic  OopJwro- Salpingitis. 

precaution,  for  it  always  presents  a  small  protrusion  of  the  diseased 
mucosa  in  the  center  of  the  stump.  When  there  is  great  difficulty 
in  isolating  the  parts,  there  is  a  natural  tendency  to  enlarge  the 
wound  in  order  to  dii'ect  the  fingers  hy  aid  of  the  eyes.  Tait  con- 
demns this  practice.  He  advises  complete  dependence  on  the  sense 
of  touch.  If  at  the  moment  of  ligature  of  the  pedicle  it  is  found 
large,  tense,  unyielding  and  threatening  to  tear  from  traction,  Tait 
advises  the  following  procedure  to  give  it  greater  laxity  :  He  glides 
Ms  fingers  along  the  broad  hgament  to  its  pelvic  insertion,  and, 
scraping  with  his  nails,  produces  fraying  of  the  serosa  and  of  the 
fibrous  textiu-e  of  the  hgament.  These  small  detachments  do  not 
affect  the  vessels,  as  they  escape  by  reason  of  their  elasticity  and 
their  mobility.  A  gi-eater  play  is  thus  given  to  the  broad  Hgament 
and  the  pedicle  is  more  easily  dra^Ti  toward  the  wound  and  tied 
without  cutting  or  tearing  it. 

The  best  means  of  arrestmg  haemorrhage  in  this  operation  is  by 
compression.  For  this  I  use  exclusively  the  sponge-compress. 
The  operation  is  momentarily  arrested,  and  a  firm  pressure  is  made 
with  the  hands  on  the  compresses  accumulated  in  the  wound. 
Haemorrhages  coming  from  the  decortication  of  a  tumor  iilling 
Douglas'  cul-de-sac  will  be  quickly  controlled  m  this  way.  Those 
due  to  tearing  of  the  sm-face  of  the  uterus  are  more  persistent  and 
may  requii-e  a  catgut  suture.  Douching  with  very  hot  water,  or 
touching  with  the  thermo-cautery,  may  be  used  if  needed.  Only  in 
cases  of  absolute  necessity  will  it  be  necessary  to  resort  to  haemostatic 
tamponnement  of  the  peritonaeum  with  iodoform  gauze,  or,  as  a 
last  resort,  to  forceps  left  in  the  wound.  In  the  latter  case  cap- 
illary di-aiuage  wiU  be  added  by  enveloping  the  forceps  in  iodoform 
gauze.  Some  surgeons  have  even  been  forced  to  pei'form  hyster- 
ectomy to  obtain  haemostasis  when  the  haemorrhage  proceeds  from 
uterine  adhesions. 

If  there  has  been  an  effusion  of  pus,  or  irritating  liquid  into  the 
abdomen,  irrigation  of  the  peritonaeum  will  be  necessary,  and  if 
the  manipulations  have  been  particularly  difficult,  and  if  an 
abundant  oozing  is  feared  from  extensive  lacerations,  drainage  or 
antiseptic  tampon  may  be  used.  In  my  practice  this  last  pre- 
caution is  the  rule  when  there  exists  a  fistula,  and  this  wiU  usually 
be  obliterated  at  once  after  the  operation  ^vithout  infection  of  the 
peritonaeum.  If  this  obliteration  be  tardy  the  tamponnement  will 
be  a  j)erfect  protection  to  the  serous  cavity. 

Eeasouing  from  the  tendency  of  the  disease  to  invade  the  sound 
tube,  should  both  these  organs  be  systematically  removed  when 
only  one  is  diseased  ?  I  believe  that  this  will  be  to  make  a  too  easy 
sacrifice  of  the  woman's  possibilities  for  fecundation,  and  that  it 
will  be  better  to  take  the  risk  of  a  second  operation.  There  are  few 
Burgeons  who  are  as  radical  on  this  point  as   Lawson   Tait.     It 


Cystic  Oophoro- Salpingitis.  393 

appears  that  the  surgery  of  the  tubes  having  passed  the  period  of 
excess,  is  now  about  to  enter  upon  a  more  conservative  era.  I  have 
ah-eady  noted  the  tendency  of  some  authorities  to  confine  them- 
selves to  the  liberation  of  adhesions  and  to  au  antiseptic  toilet  iu 
all  cases  where  the  laparotomy  has  shown  only  a  slight  alteration 
of  the  appendages.  Martin  sometimes  confines  himself  to  opening 
the  pavilion  and  separating  the  agglutinated  fimbriae.  In  cases  of 
hydrosalpinx  he  has  even  resected  a  portion  of  the  sac  and  sutured 
the  internal  to  the  external  wall,  so  as  to  create  a  permanent 
reopening,  a  vitable  artificial  pavilion  that  would  permit  fecun- 
dation. Skutsch  reports  an  operation  of  this  nature  for  which  he 
proposes  the  term  salpingotomy.  In  place  of  extirpating  the  tube, 
when  transformed  into  a  serous  cyst,  he  assures  himself  as  to  the 
nature  of  its  contents  by  aspiration,  opens  the  abdominal  extremity 
by  excising  an  oval  piece  of  one  centimeter  and  reunites,  with  silk, 
the  mucous  and  the  serous  membranes  around  the  orifice.  A  sound 
passed  into  the  tube  establishes  its  permeability.  Skutsch  asks  if 
it  would  not  be  better  in  such  cases  to  suture  the  new  pavilion  to 
the  ovary.  Certainly,  if  similar  operations  have  good  chances  of 
remedying  the  sterility,  we  could  resort  to  them,  although  they  are 
much  longer,  more  laborious  and  more  gi'ave  than  salpingotomy. 
But  this  fortunate  result  is  doubtful,  for  it  is  necessary  not  to  lose 
sight  of  the  fact  that  the  structure  of  the  organ  is  deeply  altered 
and  that  permeability  alone  is  not  sufficien':  to  insure  its  functions. 
After  other  similar  operations,  Martin  ha^  not  yet  seen  pregnancy 
follow. 

It  must  be  remembered  that  the  good  effects  of  ablation  of  the 
tubes  and  ovaries  may  not  be  perceived  until  some  weeks  or  even, 
months  have  passed.  During  this  time  the  patient  may  continue 
to  feel  abdominal  pains  that  will  make  her  believe  that  the  operation 
has  not  accomplished  its  ends.  These  phenomena  may  be  attributed 
to  two  causes :  to  the  peritonaeal  irritation  around  the  ligature, 
which,  having  been  placed  on  inflamed  tissues,  induces  a  certain, 
peripheral  reaction,  and,  to  the  persistence  of  the  inflammation  in 
the  stump  of  the  tube  left  by  the  operation.  I  believe  it  is  always 
necessary  to  remove  as  much  of  the  tube  as  possible,  leaving  onlj' 
enough  attached  to  the  uterus  to  fix  the  ligature  soHdly.  Finally,, 
every  operation  on  the  tubes  should  be  followed  by  curetting  the 
uterine  cavity,  and  by  injections  of  iodine  to  powerfully  modify  the 
accompanying  endometritis  and  to  cure  at  the  same  time  the 
inflammation  remaining  iu  the  stump  of  the  tube.  I  generally 
perform  this  curetting  at  the  end  of  the  month.  When  both  tubes 
and  both  ovaries  are  removed,  the  menopause  does  not  follow 
immediately  in  all  cases.  Cases  in  which  the  menses  still  persist 
for  a  greater  or  less  period  of  time,  are  cases  which  may  result  in 
a  lesion  of  the  uterus  (endometritis,  etc.),  hence  the  utility  of  an 


394  Cystic  Oophoro- Salpingitis. 

after-treatment,  for  the  ablation  of  the  tubes  alone  does  not  cause 
cessation  of  the  menses,  although  Lawson  Tait  makes  these  organs 
plaj'  the  preponderant  role  in  the  menstrual  function.  However, 
salpingotomy  alone  (\\ithout  oophoi-otomy)  causes  sterility. 

Gravity  of  the  operation  (oophoro-salpingotomy  for  an  inflam- 
matory lesion,  Tait's  operation). — The  statistics,  to  have  a  true 
value  and  to  permit  judgment  on  the  gravity  of  the  operation, 
should  be  arranged  by  carefuUy  establishing  the  following  classes : 

1.  Acute  catarrhal  salpingitis  (non-suppuratmgj. 

(  a.  Non-cystic. 

2.  Suppurating  salpingitis,  .j  b.  Cystic,  eniicleable. 

[  c.  Cystic,  non-en  ucleable. 

3.  Chronic  salpingitis  (hypertrophic  and  atrophic). 

4.  Serous  and  sanguineous  cystic  salpingitis  (haematosalpinx  and  hydrosalpinx). 

Unfortunately,  there  are  few  of  the  pubUshed  series  in  which 
these  distinctions  can  be  established.  It  is  in  some  degi-ee  possible 
to  affirm  fi'om  these  reports,  however,  that  the  operation  is  usually 
benign.  In  pyosalpinx  it  is  a  serious  operation,  and  becomes  more 
grave  as  the  suppuration  extends  beyond  the  appendages  invading 
the  cellular  tissue  and  the  contiguous  peritonaeum.  The  presence 
of  a  purulent  fistula  also,  adds,  without  doubt,  to  the  gravity  of  the 
operative  prognosis.  Finally,  the  general  state  of  the  patient 
should  be  taken  into  consideration.  There  is  sometimes  such  a 
state  of  exhaustion,  that  an  operation  made  in  extremis  has  but  little 
chance  of  success.  Again,  there  is,  in  some  eases,  a  veritable  resur- 
rection, and  the  surgeon  has  no  right  to  refuse  to  give  a  patient  this 
last  chance. 

I  will  confine  myself  to  some  of  the  more  recent  series  that  have 
been  published.  Meinert  has  had  thirteen  recoveries  out  of  four- 
teen operations.  Munde  has  had  a  single  death  out  of  fom-teen 
operations.  Imlach,  out  of  forty-one  operations  has  had  tkree 
deaths.  Lawson  Tait,  out  of  a  series  of  sixty-thi-ee  cases,  had  one 
death.  Orthmann  reports  twenty-one  cases,  with  two  deaths. 
Schlesinger,  out  of  two  hundred  and  seventy-four  laparotomies  for 
inflammation  of  the  tubes,  wliich  he  has  collected,  has  found  8.76 
per  cent  mortality.  A.  Mai-tin  reports  seventy-two  cases,  \\'ith 
twelve  deaths.  Westermark  has  made  ten  ablations  of  the  tubes, 
with  one  death;  he  has  collected  four  hundred  and  ninety-eight 
cases  from  eight  operators,  with  forty-one  deaths  (eight  per  hundi'ed). 
Skene-Keith,  out  of  twenty-tlu-ee  operations  in  six  months,  has  not 
had  a  failure. 

All  these  series,  in  truth,  relate  to  lesions  of  difi'erent  and  unde- 
termined intensity.  The  best  series  of  operations  for  pyosalpinx  is 
that  of  Gusserow  -.  twenty-nine  cases  out  of  tliirty  cases. 

In  France,  ablation  of  inflamed  tubes  has  frequently  been 
practiced  during  the  last  few  years.    Terrillon  has  had  six  recoveries 


Cystic  Ooplwro- Salpingitis.  395 

out  of  six  salpingotomies  for  mere  catarrhal  salpingitis.  In  one 
case  the  operation  was  unilateral.  For  cystic  salpingitis,  Terrillon 
has  had  the  following  results :  two  hydrosalpinx,  cured ;  five 
hematosalpinx,  cured;  fourteen  pyosalpinx  extu-pated  have  given 
thirteen  cured  (five  pyosalpinx  with  more  or  less  adhesions,  have 
heen  treated  by  incision  and  suture  to  the  abdominal  wall ;  they 
were  cured,  but  two  left  fistulas,  wliich  persisted  for  some  months). 

In  a  recent  discussion  at  the  Societe  de  Chirurgie,  different  small 
series  were  reported.  Eoutier,  out  of  thirteen  cases  of  pyosalpinx, 
has  had  three  deaths ;  one  operation  for  hydrosalpinx,  one  death. 
In  this  last  case  there  were  very  extensive  adhesions,  and  the 
operation  was  on  the  point  of  being  abandoned.  Terrier  has  had 
three  recoveries  out  of  four  operations  for  pyosalpmx ;  one  hemato- 
salpinx, cm-ed.  Quenu  has  had  four  successes  out  of  four  salpin- 
gotomies for  inflammation  of  the  tubes,  three  of  which  suppurated. 
J.  S.  Championniere  has  published  the  following  results :  sixty- 
five  ablations  of  the  appendages  and  ten  liberations  of  adhesions, 
with  only  one  death.  It  is  to  be  regretted  that  in  this  important 
series  the  lesions  had  not  been  classed  in  distinct  categories, 
permitting  their  respective  gravity  and  the  surgical  value  of  the 
operative  results  to  be  appreciated. 

In  resume  the  mortality,  very  small  in  catarrhal  salpingitis,  rises 
in  pyosalpinx  and  even  in  hydro-  or  hsematosalpinx ;  we  find,  then, 
in  fact,  adhesions  which  singularly  comphcate  the  operation.  But, 
even  then,  the  mortality  is  relatively  small,  and  altogether  out  of 
proportion  to  the  excessive  gravity  of  the  expectant  treatment. 


396  I'lrimetro-Salpiiigitis. 


CHAPTER  XXIX. 


PERIMETRO-SALPINGITIS. 

The  confusion  wliieh  has  reigned  in  regard  to  the  pathology  and 
the  nomenclature  of  the  diffuse  inflammations  of  the  pehic  cavity 
has  not  yet  wholly  disappeared.  However,  from  the  knowledge  of 
inflammations  of  the  tulies  recently  acquii'ed  hy  the  study  of  clinical 
facts,  we  are  ariving  at  clearer  and  simpler  views  of  the  subject. 
To-day  we  know  that  if  the  point  of  departure  is  frequently  in  the 
uterus,  it  is  still  more  frequently  that  it  is  from  a  salpingitis  that 
the  inflammation  radiates  to  invade  the  uterine  surroundings,  the 
broad  ligament,  Douglas'  cul-de-sac  and  the  peh^ic  cellular  tissue. 
It  is  proper,  then,  to  bring  the  tube  into  the  nomenclature  of  the 
disease  and  to  reunite  all  these  lesions  under  the  geneiic  term, 
perimetrosalpingitis.  This  invasion  is  made  Mith  clinical  characters 
that  are  very  dift'erent  in  their  progress  and  their  intensity,  ac- 
cording to  the  setiological  conditions  in  wliich  they  occur.  From 
this  arises  a  series  of  distinct  clinical  tjTses  although  the  same 
pathogeny  unites  all  these  species  in  a  common  genus. 

Histm'ical  sketch. — The  more  violent  forms  were  first  observed, 
and  the  great  and  rapid  suppuration  which  succeeds  to  a  localized 
septicaemia  of  puerperal  origin  was  described.  Grisolle  and  Bour- 
don mark  by  then*  work  tliis  iu'st  step.  Phlegmon  of  the  broad  lig- 
ament was  still  confounded  with  abscess  of  the  iliac  fossa  of 
entirely  different  origin.  Nouat,  Yalleix  and  their  pupils  made 
another  advance  in  the  clinical  knowledge  of  the  periuterine  inflam- 
mations by  describing  the  more  limited  purulent  collections  pro- 
duced behind  and  at  the  sides  of  the  uteiais.  These  authors 
localized  them  in  the  cellular  tissue  which  existed,  according  to 
their  ideas,  not  only  between  the  folds  of  the  broad  ligament,  but 
also  around  the  supravaginal  portion  of  the  cer\-ix,  especially  pos- 
teriorly. Interminable  discussions,  more  theoretical  than  practical, 
followed.  In  fact,  at  the  same  time,  another  interpretation  of  the 
same  facts  was  brought  forward.  Bernutz  and  Goupil,  after  a 
remarkable  description  of  the  clinical  phenomena  that  we  refer  to- 
day to  circumscribed  or  diffuse  inflammation  of  the  tnlies,  attril)uted 
them,  Arithout  exception,  to  inflammations  of  the  peh-ic  peritonamm, 
topehi-peritonitis.  Others  admitted  l)oth  the  foregoing  methods  of 
origin.  Duncan  created  the  words,  perimetritis  and  parametritis, 
to  distinguish  the  inflannnationof  the  peritonteum  from  that  of  the 
circumuterine  cellular  tissue. 


Perimetro-Saljnngitis.  397 

A  new  interpretation  of  a  series  of  analogous  facts,  if  not  identical, 
was  again  proposed.  The  role  of  the  lymphatics  in  the  periuterine 
inflammations  after  delivery  was  brought  forward  by  some  authors. 
J.  L.  Championniere  attributed  to  them  much  more  importance  and 
extended  their  role  beyond  the  puerperal  state.  Alphonse  Guerin 
believed  in  the  discovery  of  a  new  clinical  type  and  of  a  different 
location  of  inflammation  around  the  uterus,  which  he  described  as 
juxtapubic  adenoplilegmon.  The  origin  was  referred  to  a  retro- 
pubic or  obdurator  lymphatic  ganglion  as  well  as  the  difi^ereiit 
vessels  distributed  under  the  peritonaeum  and  around  the  laterus. 
Whenever  the  supposed  plilegmon  of  the  broad  ligament  extends  to 
the  cellular  tissue  of  the  abdominal  wall,  we  then  have,  according  to 
Guerin,  a  juxtapubic  adenophlegmon.  Besides  Guerin,  L.  Cham- 
ponnierre,  Gueneau  de  Mussy,  Siredey  and  Martineau  admitted 
adenolymphangitis  as  an  explanation  of  the  more  circumscribed 
inflammations,  peri-  and  parametritic.  The  lymphatic  interpre- 
tation from  that  time  was  in  favor  and  no  role  was  attributed,  either 
to  the  cellular  tissue,  or  to  the  peritonaium.  In  tliis  theory,  as  in 
the  preceding,  the  inflammation  originated  in  the  uterine  mucosa 
and  the  initial  metritis  demanded  all  the  attention  of  the  surgeon. 

Early  in  this  discussion  another  theory  was  timidly  brought  for- 
ward, but,  in  default  of  sufficient  proof,  did  not  receive  the  attention 
that  it  merited.  Aran  was  the  first  who  saw  clearly  the  extreme 
importance  of  the  ovary  and  of  the  tube  in  uterine  pathology.  He 
showed  plainly  that  these  organs  formed  the  central  focus  around 
which  the  pus  and  false  membranes  collect.  Some  isolated  obser- 
vations on  this  subject  were  published,  but  passed  unnoticed. 

To-day  there  is  a  tendency  to  return  to  the  doctrine  of  Aran,  with- 
out affirming,  with  enough  decision,  however,  that  it  is  the  only 
theory  which  explains  all  the  periuterine  inflammations.  The  most 
recent  authors  still  adhere  to  a  separate  description  for  parametritis 
and  perimetritis,  sometimes  adding  adenolymphangitis.  For  my- 
self, I  hold  firmly  to  the  doctrine  of  Aran.  The  facts  that  I  have 
observed  show  that  almost  all  the  peri-  and  parauterine  inflam- 
mations arise  only  from  salpingitis  and  perisalpingitis.  The 
lymphatics  certainly  play  a  considerable  role,  but  this  role  is  itself 
subordinate  to  the  previous  inflammation  of  the  uterine  mucosa 
and  its  prolongation  in  the  oviducts.  Now  it  is  the  primary 
phenomenon  which  should  give  its  name  to  the  disease. 

I  shall  describe  successively  the  diverse  anatomical  forms  that 
inflammation  around  the  uterus  and  its  appendages  may  assume 
by  commencing  with  the  lesser  and  passing  to  more  and  more  grave 
forms.  The  clinical  types  are  :  1.  Serous  perimetro-salpingitis ; 
2.  Peh-ic  abscess;  3.  Phlegmon  of  the  broad  ligament ;  4.  Diffuse 
pelvic  cellulitis. 

Pathological  anatomy. — 1.    Serous  j>crimetro-salpingitis. — It  is  not 


398  Perimetrosalpingitis. 

in  autopsies  that  tliis  lesion  can  be  observed,  but  it  is  possible  to 
see  it  very  distinctly  in  the  course  of  some  operations.  I  have,  in 
two  eases,  found  an  tederaatous  infiltration  of  the  broad  Ugament 
around  a  tube  attacked  by  purulent  salpingitis.  Before  the  lapar- 
otomy and  by  bimanual  palpation,  this  infiltration  gave  the  sensation 
of  a  large  tumor  wliich  could  be  attributed  to  the  tube  itself. 
Lymphangitis  certainly  plays  a  considerable  role  in  this  acute 
ledema  by  giving  rise  to  inflammatory  nuclei.  A  proof  of  this  is 
found  in  the  engorgement  that  is  sometimes  produced  in  the  inguinal 
ganglia,  which  communicate  \vith  the  lymphatics  of  the  surface  of 
the  uteiiis  by  a  small  vessel  which  follows  the  round  ligament  (Fig. 
205).  These  hard  cedemas  may,  without  doubt,  invade  the  lax 
cellular  tissue,  that  surrounds  the  ovary,  under  the  influence  of  an 
acute  impulse  of  the  salpingitis  which  serves  them  as  a  nucleus. 
It  is  not  inadmissible  that  an  effusion  of  muco-pus  or  of  blood  from 
the  inflamed  mucosa  may  irritate  Douglas'  cul-de-sac  into  which  the 
appendages  are  so  often  prolapsed  (Tait).  However,  intermittent 
inflammatory  cedema  around  the  diseased  appendages  cannot  be 
disputed.  Direct  observation  has  sho^^ii  it  and  induction  authorizes 
us  to  invoke  it,  with  Sinety,  in  cases  where  voluminous  masses 
appear  and  disappear  in  a  few  days  at  the  sides  of  the  uterus. 

To  this  inflammatory  cedema  of  the  subperitonteal  coimective 
tissue,  comparable  anatomically  with  the  experimental  oedema  pro- 
duced by  Eauvier's  procedure,  is  sometimes  added  a  secretion  of 
serum  between  the  false  membranes  around  the  appendages  and 
especially  in  Douglas'  cul-de-sac,  forming  serous  collections. 
Capillary  punctures  made  in  these  circumstances  for  therapeutic 
purposes  have  put  this  fact  beyond  dispute,  and  have  proven  the 
fi'equency  of  its  occurrence.  Besides,  it  has  been  found  in  the 
course  of  some  laparotomies.  A.  Doran  has  pubhshed  a  curious 
case  where  a  serous  collection  of  this  nature  was  taken  after  opening 
the  abdomen  for  a  sarcoma  of  the  ovary,  that  the  operator  dared 
not  extirpate.  The  rapid  disappearance  of  the  tumor  left  no  doubt 
as  to  its  nature.  Such  is  the  first  degree  of  periuterine  inflam- 
mation. It  presents,  in  an  immense  majority  of  cases,  a  very 
definite  clinical  type,  that  of  acute  ephemeral  exacerbations  in 
inflammations  of  the  appendages.  Here,  too,  belongs  the  obscure 
circumscribed  parametritis,  that  has  been  invoked  to  explain  the 
relaxation  or  the  retraction  of  the  uteiine  ligaments  (Schultz). 

Suppurating  perimetro-salpingitis  presents  two  very  different 
clinical  types.  One  corresponds  to  the  advanced  stages  of  the  pelvi- 
peritonitis of  some  authors,  as  salpingitis  and  pyosalpinx  correspond 
to  the  first  stages,  it  is  pelvic  abscess.  The  other,  phlegmon  of  the 
broad  ligaments,  is  characterized  by  a  particular  mode  of  extension 
of  the  suppuration  determined  by  certain  etiological  circumstances. 

2.  Pelvic  abscess. — This  expression  should  not  be  taken  in  its 


Periinetro-Salpingitis.  399 

former  sense.  In  fact  a  large  pyosalpinx,  which  forms  a  large  pur- 
ulent pocket  adherent  over  a  great  part  of  its  surface  to  the  pelvic 
cavity,  has  long  been  mistaken  for  the  collections  of  encysted  pelvi- 
peritonitis, or  for  abscess  developed  under  the  peritonteal  fold  and 
Avrongly  called  pelvic  abscess.  Its  true  origin  is  certainly  difficult 
to  demonstrate  and  demands  a  decortication  of  the  tubal  sac,  which 
the  earlier  operators  dare  not  undertake,  even  had  they  believed  it 
possible.  When  there  is  found,  on  opening  the  abdomen,  a  sac 
equal  to  the  volume  of  the  two  fists,  or  larger,  circumscribed  on  all 
sides,  seemingly  continuous  behind  with  Douglas'  cul-de-sac,  which 
it  fills,  adherent  at  the  sides  to  the  pelvis  and  above  to  the  omentum 
and  even  to  the  intestine,  it  is  very  natural  to  think  of  an  abscess 
formed,  either  in  the  subperitoneal  tissue  (parametritis),  or  in  the 
peritonaeum  partitioned  off  by  false  membranes  (pelvi-peritonitis). 
This  corresponds,  however,  in  the  great  majority  of  cases,  to  a 
purulent  tubal  cyst,  which,  at  first  free,  has  become  adherent  by  the 
subsequent  changes.  This  is  confirmed  by  a  bold  decortication  of 
the  sac.  When  this  procedure,  often  very  laborious,  is  concluded, 
there  is  found  a  cyst  furnished  with  an  internal  pedicle  inserted  on 
the  cornu  of  the  uterus,  and  it  wiU  be  recognized  as  a  dilated  tube. 
The  major  part  of  supposed  pelvic  abscesses  treated  by  laparotomy 
and  incision,  without  attempt  at  total  extirpation,  by  Tait,  Hegar, 
Terrillon,  etc.,  for  some  years,  have  been  only  cases  of  adherent 
pyosalpinx,  which  one  should  really  attempt  to  extirpate  bodily. 
Their  clinical  history  and  operative  treatment  belong  to  the  chapter 
on  pyosalpinx. 

There  remain  however,  among  the  encysted  collections,  a  certain 
number  of  cases  where  the  fusion  with  the  contiguous  parts  is  such 
that  a  total  extirpation  will  be  impossible  or  too  dangerous.  These 
facts  can  be  justly  differentiated  by  a  special  appellation,  and  the 
name  of  pelvic  abscess  can  be  preserved  by  specifying  that  it  will 
be  reserved  for  non-enucleable  purulent  collections.  This  name 
has  then  a  surgical  rather  than  an  anatomical  value.  In  fact,  at 
the  autopsy,  it  is  generally  impossible,  in  these  advanced  cases,  to 
obtain  an  exact  knowledge  of  the  nature  of  the  abscess  wall,  and  to 
decide  whether  it  relates  to  the  peritonaeum,  to  a  false  membrane, 
or  to  the  wall  of  a  dilated  tube.  Among  the  pelvic  abscesses  should 
be  classed,  for  the  same  reason,  some  cysts  inch;ded  in  the  broad, 
ligament,  some  haematoceles  that  have  suppurated,  with  transfor- 
mation into  k  purulent  coUection,  into  abscess,  adherent  on  all  sides 
and  indissoMbly  to  the  soft  or  to  the  hard  parts  of  the  pelvis. 
Among  the  cases  of  pelvic  abscesses  cured  by  laparotomy  which 
Lawson  Tait  has  reported,  there  is  one  that  originated  in  an  extra- 
peritonael  intra-ligamentous  pregnancy.  No  vestige  of  the  foetus 
was  found  in  the  pus,  but  only  debris  of  the  placenta. 

The  intimate  adherence  of  a  pyosalpinx  to  the  pelvic  walls  or  to 


400  Perimetro-Salpiii(iith. 

the  organs  contained  in  the  pelvis  is  a  first  step  toward  spontaneous 
opening.  This  has  an  especial  tendency  toward  the  rectum.  After 
the  first  evacuation  of  the  sac,  which  empties  it  momentarily, 
another  occurs  and  soon  the  communication  between  the  sac  and 
the  rectum  l)ecomes,  if  not  permanent,  at  least  regularly  intermit- 
tent. These  fistulie  are  also  rarely  produced  in  the  vaginal  cul-de- 
sac.  Finally,  if  the  development  of  the  abscess  occurs  soon  after 
delivery  when  the  appendages,  r;plifted  by  the  ascension  of  the 
grand  uterus  have  a  tendency  to  fall  forward,  the  suppuration  may 
occur  in  the  anterior  portion  of  the  pelvic  cavity  and,  after  becom- 
ing established  in  the  prevesical  cavity  of  Eetzius,  perforate  toward 
the  groin  or  toward  the  umbilicus.  These  fistulous  pelvic  abscesses 
constitute  the  most  important  variety.  At  a  late  period  they  are 
reduced  to  a  siuus  of  smaller  calibi'e  but  very  sinuous  and  sur- 
rounded liy  indurated  tissue  that  makes  it  exceedingly  difficult  to 
heal. 

Klob  has  noted  a  frequent  fatty  degeneration  of  the  muscular 
fibres  of  the  uterus  in  the  A-icinity  of  pelvic  suppurations.  I  have 
had  occasion  to  observe  it.  It  is  particularly  appreciable  on  at- 
tempting to  decoi-ticate  a  sac  adherent  to  this  organ. 

Indurated  masses  formed  by  the  infiltration  and  proliferation  of 
connective  tissiie  often  exist  around  the  limits  of  the  pelvic  abscess 
and  extend  to  a  greater  or  less  distance  from  it.  They  may  sun'ive 
its  evacuation  and  form  a  residuum  that  is  long  in  disappearing. 
The  omentum  may  also  present  the  hard  masses  of  chi-onic  inflam- 
mation. These  lesions  disappear  quickly  after  the  evacuation  of 
the  purulent  focus. 

Phlegmon  of  the  broad  ligament  is  almost  always  the  result  of  a 
recent  delivery ;  the  celltdar  tissue  of  this  fold  has  been  distended 
and  relaxed,  and  the  veins,  having  become  varicose,  are  the  seat  of 
tlu'ombus  or  even  present  ruptures,  permitting  effusion  of  blood. 
Such  an  anatomical  condition  is  eminently  propitious  for  a  rapid 
invasion  of  si;ppuration.  Wiat  is  its  exact  point  of  departure  ? 
Does  the  infection  come  from  the  inflamed  tubes  which  occupy  the 
upper  border  of  the  fold,  or  is  it  a  true  lymphangitis  of  the  large 
trunks  which  supply  the  broad  ligament?  Both  processes  are 
probable  and  may  exist.  What  is  important  to  keep  in  view  is  the 
.prenous  anatomical  state  which  permits  the  lesion  to  take  at  once 
a  special  character,  that  of  a  phlegmon  having  a  tendericy  to  dif- 
fusion, very  different  from  a  circumscribed  abscess. 

There  exist  only  a  few  exact  anatomical  papers  on  tliis  affection. 
In  an  autopsy  published  by  Lewers  some  inteiesting facts  are  noted. 
The  two  leaflets  of  the  peritomeum  were  separated  by  an  abundant 
exudation,  which  extended  from  the  inferior  border  of  the  tube  to 
tlie  base  of  the  ligament  below  and  to  the  pelvic  wall  outward.  The 
tube  was  drawn  downward  but  the  author  gives  no  detailed  account 


Perimetro-Salpingitis.  401 

of  its  anatomical  condition,  which  be  does  not  seem  to  have  noted, 
although  he  expressly  describes  a  small  abscess  in  the  ovary,  and 
says  that  its  surface  adheres  by  recent  exudations  to  the  face  of  the 
broad  ligament.  It  is  then  extremely  probable  that  the  tube  was 
diseased,  and  in  any  event  the  broad  ligament  could  have  been 
infected  by  the  suppurating  ovaiy.  Section  of  the  broad  ligament 
revealed  an  areolar  tissue,  similar  to  a  large  sponge,  with  cavities 
filled  with  sero-sangumolent  Hquid.  In  an  autopsy  reported  by 
Carter  the  section  of  the  broad  ligament  presented  the  appearance 
of  an  interstitial  injection  of  a  plastic  material  separating  the  normal 
elements,  maintaining  the  veins  distended  and  the  lymphatics  fixed 
and  gaping. 

The  inflammatory  infiltration  is  easily  propagated  outward  under 
the  peritonaeum  along  the  ilio-psoas  muscle  to  the  anterior  and 
superior  iliac  spine  and  hence  it  opens  into  the  subcutaneous  adi- 
pose tissue  by  the  weak  points  in  the  muscular  aponeurotic  layer, 
at  the  vascular  and  nervous  orifices.  As  soon  as  the  purulent  sac 
has  come  in  contact  with  the  abdominal  walls,  it  becomes  adherent 
and  in  consequence  gives  rise  to  the  sensation  of  a  resisting  breast- 
plate. Suppuration  usually  siicceeds  to  the  infiltration,  but  it  may 
not  in  some  cases.  The  process  is  arrested  and  the  phlegmon 
absorbed,  leaving  only  some  indurated  cellular  masses.  Under  these 
circumstances,  I  have  observed  a  curious  and  Httle-known  phe- 
nomenon which  follows  long  after  the  symptoms  of  periuterine 
inflammation  appear  to  have  entirely  subsided.  Then,  after  this 
apparent  termination,  there  occur  the  symptoms  of  a  suppurative 
focus,  more  or  less  distant  from  the  place  of  origin,  toward  the  iliac 
fossa,  in  the  sheath  of  the  psoas,  and  in  the  perinephritic  cellular 
tissue.  There  appear  to  remain  traces  of  a  septic  infection  which 
evolves  late,  after  having  lost  its  relation  to  the  first  point  of 
departure.  It  is  also  probalile  that  the  lymphatics  play  an  im- 
portant part  in  these  secondary  abscesses  that  are  analogous  to 
those  produced  in  other  regions  several  days  after  the  disappearance 
of  a  lymphangitis. 

In  all  the  preceding  facts  the  septic  infection  was  more  or  less 
localized  and  terminated  in  lesions  contained  within  certain  limits. 
It  is  not  always  so ;  after  some  puerperal  infections,  the  infiltration 
extends  rapidly  to  all  the  pelvic  cellular  tissue,  like  a  malignant 
erysipelas,  hence  the  name,  eri/sipelas  malignum  imcrperale,  which 
Virchow  gave  it.  The  cedematous  tissues  have  a  livid  hue,  the 
lymphatics  are  filled  with  micrococci,  and  the  veins  contain  clots  or 
pus.  These  cases  are  almost  surely  fatal.  The  importance  of  the 
lymphatics  is  here  beyond  doubt.  There  is  a  true  septic  lymphan- 
gitis including  all  that  surrounds  the  genital  apparatus.  This  is  the 
clinical  type  for  which  I  propose  to  reserve  the  term,  diffuse  jielric 
cellulitis. 


402  Prri  metro-  Snip  i  iigitis . 

General  Etiology. — I  will  not  return  to  what  has  l)eeii  said  relative 
to  the  aetiology  of  inflammations  of  the  tubes  and  which  applies 
here,  for,  with  the  exception  of  diffuse  pelvic  cellulitis,  which  con- 
stitutes a  distinct  class,  all,  or  almost  all,  the  periuterine  inflam- 
mations are  only  extensions  from  a  tubo-ovarian  focus.  I  shall 
limit  myself  to  noting  the  etiological  circumstances  peculiar  to  the 
different  classes  I  have  distinguished. 

The  nuclei  of  inflammatory  cedema  are  observed  in  the  course  of 
all  the  forms  of  acute  or  chronic  inflammation  of  the  tubes.  Pelvic 
abscesses  succeed  to  pyosalpinx,  or  to  the  suppuration  of  an  ovarian 
cyst,  or  to  a  pelvic  hitmatocele  in  the  vicinity  of  an  inflamed  tube. 
Temporizing  too  long,  too  prolonged  or  too  violent  explorations  favor 
theii-  formation.  Is  phlegmon  of  the  broad  hgament  observed  out- 
side of  the  puerperal  state  to  which  I  have  referred  the  predisposing 
influence  ?  Bernutz  admits  that  out  of  twenty  cases,  he  had  seven- 
teen which  depended  on  the  puerperal  state.  Frarier  holds  that 
plilegmon  of  the  broad  ligament  is  never  observed  except  from 
puerperal  causes.  This  opinion  is  too  exclusive,  for  infection  of  the 
uterus  by  septic  operations  appears  to  have  caused  the  same  trouble. 
However,  it  is  always  an  index  of  an  infection  which  is  more  intense 
and  of  a  more  rapid  evolution  than  that  producing  circumscribed 
pelvic  abscess.  Finally,  diffuse  pehdc  cellulitis  may  follow  in  the 
same  conditions,  parturition  or  any  operation  on  the  genital  passages 
performed  in  exceptionally  septic  conditions.  It  is  quite  com- 
parable to  the  cellulitis  that  sometimes  follows  after  serious  oper- 
ations on  the  bladder  or  on  the  rectum. 

Symptoms  and  diagnosis. — I.  Serous  perimetrosalpingitis. — The 
symptoms  of  the  inflammation  propagated  around  the  tubes  and 
the  uterus,  in  its  most  benign  form,  are  those  that  I  have  described 
briefly  in  the  chapter  on  salpingitis  finder  the  head  of  acute  exacer- 
bations. The  description  has  been  given  by  other  authors  but  under 
different  names.  Peter  and  Gueneau  de  Mussey  have  noted  them 
Avithout  specifying  then-  exact  localization.  Martineau  attributes 
them  to  periuterme  adenitis.  Courty  also  admits  the  lymphangitic 
origin.  Munde  and  Mai-tin  have  accepted  it.  Cautin  has  devoted 
a  work  to  the  defense  of  this  opinion. 

Besides  the  symptoms  of  concomitant  salpingitis,  there  are  those 
proper  to  the  contiguous  inflammation  surrounding  the  tubes.  The 
patient  complains  of  a  recnidescence  of  her  habitual  malaise.  It  is 
rare,  however,  that  there  is  a  marked  febrile  movement.  Only  a 
little  gastric  disturbance  is  noted.  On  vaginal  examination  there 
is  found  a  greater  sensitiveness  in  the  culs-de-sac.  Sometimes  a 
sharp  and  localized  pain  draws  a  complaint  from  the  patient  each 
time  that  the  finger  touches  in  the  same  place.  There  may  be  a 
general  dougloiness  of  the  region,  especially  if  similar  or  more 
severe  attacks  left  adhesions  which  lixed  the  uterus.     In  these  cases 


Perimetro-Salpingitis.  403 

the  signs  furnished  by  local  examination  may,  at  the  time  of  a 
simple  exacerbation  of  this  nature,  assume  an  apparent  gravity 
against  which  the  inexperienced  must  be  guarded.  The  mildness 
of  the  general  symptoms  forbid  a  grave  prognosis.  In  fact,  at  the 
end  of  some  days,  the  doughiness  will  give  place  to  tumors  inde- 
pendent of  the  uterus  which  may  become  quite  mobile.  There  are 
generally  several  nuclei  in  the  posterior  and  lateral  culs-de-sac.  They 
give  the  sensation  of  rounded  glands,  more  or  less  sensitive  to  touch. 
The  changes  that  these  tumors  undergo  are  very  rapid,  so  much  so 
that  unless  daily  explorations  have  been  made  one  would  almost 
believe  himself  the  victim  of  an  illusion  (de  Sinety). 

Sometimes  very  hard  nuclei  may  persist  for  a  long  time,  their 
consistence  and  their  form  resembling  fibromata  (Gueneau  de 
Mussey).  They  are  easily  distinguished  by  the  want  of  intimate 
connection  mth  the  uterus  and  absence  of  dilatation  of  this  organ. 
The  prolapsed  ovary  is  more  voluminous,  forms  an  isolated  tumor, 
and  on  pressure  gives  a  peculiar  sickening  pain.  The  tumor  formed 
by  a  small  cyst  of  the  ovary  or  of  the  broad  ligament,  has  quite  a 
different  character;  it  is  elastic  or  fluctuating,  markedly  lateral, 
solitary,  accessible  only  to  bimanual  palpation  and  not  to  touch 
alone.  I  need  only  mention  seybalse,  which  might  confuse  the  inex- 
perienced observer.  Speculum  examination  furnishes  no  infor- 
mation. The  progress  of  these  oedematous  nuclei  and  serous  col- 
lections of  perisalpingitis  is  capricious  and  intermittent.  They 
constitute  one  of  the  elements  of  the  inflammatory  exacerbations  of 
diseases  of  the  appendages  which  have  been  described  in  the  chapter 
on  salpingitis.  They  have  a  great  tendency  to  recurrence,  but  none 
to  suppuration. 

11.— Pelvic  abscess. — This  term  is  not  limited  to  purulent  col- 
lections situated  in  the  pelvic  cavity  for,  by  right,  pyosalpinx  should 
be  included.  Surgically,  pelvic  abscess  is  a  collection  which  is 
not  fi-'ee  and  independent,  nor  susceptible  of  enucleation,  pedunculi- 
zation  and  removal,  but  a  pelvi-parietal  collection,  united  to  the 
pelvis,  which  forms  its  wall.  They  have  sometimes  been  described 
under  the  names  of  suppurating  pelvi-peritonitis  and  parametritis ; 
even  plJegmon  of  the  broad  ligament,  which  constitutes  a  very 
distinct  clinical  type,  has  been  incorrectly  included  under  the  name 
of  pelvic  abscess. 

Clinically,  pelvic  abscesses  are  most  frequently  only  an  advanced 
step  of  the  evolution  of  pyosalpinx  and  no  demarkation  separates  them 
in  the  symptomatic  point  of  view.  Sometimes,  however,  the  acute 
phenomena  mark  the  transition  of  the  suppuration  in  the  tubes  and 
ovaries  from  the  circumscribed  (pyosalpinx,  ovarian  abscess)  to  the 
diffuse  form.  If  pus  escapes  into  the  pelvic  peritonaeum,  or  simply 
rapid  diffuse  inflammation,  pain  may  suddenly  appear,  sharp, 
syncopal,  and  accompanied  with  symptoms  similar  to  those  of  peri- 


404  Perimetrosalpingitis. 

tonitis— chills,  vomiting,  tympanites,  face  pinelied.  pulse  tliread- 
like.  At  the  same  time,  fever,  wliich  may  have  been  absent 
iintilthen,  or  only  appreciable  by  frequent  use  of  the  thermometer, 
shows  itself,  generally  of  a  remittent  type,  with  evening  exacer- 
bations. There  are  also  disturbances  of  the  rectum  and  bladder, 
constipation,  dysuria,  rectal  and  vesical  tenesmus.  If  the  abscess 
protrude  on  the  side  of  the  rectum,  complete  obstruction  of  the 
bowel  may  result.  Touch  and  bimanual  palpation  should  be 
practiced  with  great  care.  It  is  necessary  to  determine  whether 
the  uterus  is  fixed,  locked  in  the  pelvis  as  if  imprisoned  in  a  casting 
of  plastic  material,  which  is  notliing  but  the  intense  inflammatory 
oedema  which  has  infiltrated  the  whole  neighboring  cellular  tissue. 
At  the  end  of  some  days  this  cedema  diminishes  and  the  protrusion 
of  the  abscess  is  then  separated  from  the  cervix  by  a  more  marked 
sulcus.  This  tumor  is  smooth,  regular,  difiicult  to  limit  superiorly  ; 
it  gives  a  sense  of  heat  to  the  finger  and  arterial  pulsation  is  often 
perceived  owing  to  the  dilatation  cf  the  vessels ;  it  is  rare  to  find 
fluctuation,  because  of  the  induration  of  the  vagina,  which  has 
sometimes  the  consistence  of  pasteboard  and  the  great  thickness 
of  the  infiltrated  tissues  which  separates  the  finger  from  the  fre- 
quently very  small  pus  cavity.  An  important  character  is  the 
immobility  of  the  uterus  and  of  the  tumor ;  they  both  appear  welded 
together.  By  bimanual  palpation  it  is  also  found  that  the  tumor 
adheres  to  the  pehdc  walls.  The  uterus  is  displaced  in  the  opposite 
direction,  the  cervix  flattened  against  the  pubes,  if,  as  is  most  fre- 
quently the  case,  the  tumor  is  seated  in  the  posterior  cul-de-sac ;  it 
may  also  lie  toward  one  side ;  finally,  more  rarely  still,  the  doughi- 
ness  may  predominate  in  front  between  the  uterus  and  bladder. 

Eectal  touch  gives  valuable  additional  information  as  to  the  con- 
nections of  the  tumor.  Examination  with  the  speculum  is  useless. 
There  may  be  a  period  of  remission  at  this  jimcture  which  may  last 
for  some  time,  according  to  the  formation  of  protecting  adhesions 
which  freely  limit  the  collection.  But,  when  the  tendency  to  evacu- 
ation is  re-established,  the  lancinating  pains  and  the  fever  are  re- 
doubled. If  the  abscess  jjoints  toward  the  posterior  cul-de-sac, 
the  vagina  presents  at  first  an  indurated  area  ;  if  it  is  toward  the 
rectum,  a  perinseal  weight  and  the  mcst  painful  rectal  tenesmus 
indicate  it.  A  very  grave  crisis  often  precedes  the  opening  into  the 
rectum,  the  vagina  or,  more  rarely,  into  the  prevesical  cellular 
tissue ;  a  sudden  relief  succeeds  to  it,  but  does  not  last  long.  The 
abscess  opens  badly  and  the  symptoms  of  cln"onic  absoi-ption  are 
manifest,  or  the  abscess  is  totally  evacuated,  but  refills  and  is 
evacuated  again  at  irregular  periods,  with  the  same  train  of  general 
symptoms.  The  patient  fills  into  a  condition  of  debility  and  a 
hectic  similar  to  that  I  have  already  described  in  connection  with 
fistulous  pyosalpinx.     At  this  time,  moreover,  the  two  affections  are 


Perimetro- Salpingitis.  405 

confused,  clinically,  and  the  difference  which  results  from  the 
various  connections  of  the  collection  (enucleable  in  one  case,  im- 
possible to  decorticate  in  the  other),  is  only  a  question  of  operative 
procedure.  In  exceptional  cases  the  patient  recovers  after  evacu- 
ation of  the  abscess.  But  they  then  often  leave  interminable  fistulae 
behind  them.  Some  cases  have  been  cited  of  rapidly  fatal  termi- 
nation by  the  opening  of  the  abscess  into  the  peritonaeum;  they  are 
very  rare,  for  the  pus  collection  usually  is  well  walled  in  by  inflam- 
matory products. 

The  pelvic  abscess  may  be  tubercular,  like  the  pyosalpinx  from 
which  it  arises ;  in  these  cases,  other  signs  of  pulmonary  tubercu- 
losis are  generally  observed. 

The  diagnosis  of  pelvic  abscess  and  of  pyosalpinx  is  easily  made 
when  there  still  exists  mobility  of  the  cystic  collection  and  when  the 
tubes  are  pedunculated ;  it  is  impossible  if  the  cystic  tumor  is  largely 
adherent  and  if  it  has  become  fistulous ;  it  is  only  by  the  study  of 
the  general  symptoms  and  by  the  history  that  one  can  then  suspect 
that  the  inflammation  has  become  more  diffuse,  and  laparotomy 
alone  wholly  settles  the  question.  Plilegmon  of  the  broad  ligament 
forms  a  lateral  tumor,  placed  upright  at  the  side  of  the  uterus ;  it 
appears  rapidly  after  a  confinement.  Pelvic  hsematocele,  at  its 
onset,  is  a  freely  fluctuating  tumor ;  it  only  causes  febrile  symptoms 
when  it  suppurates  and  is  transformed  into  pelvic  abscess. 

III. — PhlecimoH  of  the  broad  ligament. — This  is  most  frequently 
called  parametritis,  but  it  is  of  interest,  it  "seems  to  me,  to  pre- 
serve the  old  name  under  wlaich  it  has  been  known.  The  descriptions 
now  become  classic,  the  more  as  this  name  responds  quite  exactly 
to  the  principal,  if  not  the  primary,  seat  of  these  lesions.  It  usually 
shows  itself  towards  the  end  of  the  first  week  after  a  confinement 
which  has  been  rendered  septic  by  special  exposure  (epidemics, 
manipulations  made  without  sufficient  antiseptic  precautions,  etc.). 
A  severe  chill  may  mark  its  onset,  at  other  times  local  heat  is  the 
initial  symptom;  it  begins  in  the  lumbar  regions  and  radiates 
toward  the  thighs.  Loss  of  appetite  and  of  sleep,  profuse  sweat, 
small,  irregular  chiUs,  fever  of  a  remittent  character,  great  altei  - 
ation  of  the  features  announce  that  suppuration  is  going  on ; 
as  soon  as  it  has  collected  there  is  a  period  of  comparative  ease. 
If  touch  is  practiced  at  this  period,  in  the  first  days  there  is  only 
found  a  general  doughiness  of  the  culs-de-sac,  immobilizing  the 
uterus  with  predominance  of  the  tumefaction  on  one  side.  Then, 
if  a  subsequent  examination  is  made,  with  bimanual  palpation 
added,  it  is  found  that  the  doughiness  is  localized  in  a  lateral  mass, 
fused  with  the  uterus  and  fastening  it  to  the  pelvic  wall,  and  extend- 
ing to  the  superior  strait,  as  if  the  broad  ligament  were  solidified. 
A  prolongation  in  the  form  of  a  cross  generally  surrounds  the 
cervix,  from  which  it  is  separated  by  a  groove.     The  uterus  is 


406  Perimetro- Salpingitis. 

pushed  toward  the  healtliy  side,  often  in  very  marked  latero- 
version. 

It  is  not  impossible  to  have  resolution  occur  at  this  period  and  the 
disease  terminate  by  reabsorption  of  the  plastic  products  and 
nodular  retraction  of  the  broad  Ugament.  But  that  is  the  very  rare 
exception.  Generally,  after  a  short  remission,  the  chills  return  with 
profuse  sweats  and  diarrhcea,  the  general  health  becomes  more  and 
more  impaired  and  gives  a  clear  picture  of  septic  infection.  Death 
may  come  at  this  period.  It  is  more  common  to  see  the  pus  succeed 
in  opening  an  avenue  to  the  exterior,  if  the  prudent  surgeon  has  not 
anticipated  the  efforts  of  nature.  Purulent  infiltration  gains  more 
and  more  on  the  hmits  of  the  broad  ligament,  passes  then  toward 
the  vagina,  becomes  indurated,  and  gives  the  sensation  to  the  ex- 
ploring finger  which  has  been  described  as  a  vagina  of  pasteboard. 
On  the  other  hand,  inwardly  fi"om  the  antero- superior  iliac  spine, 
or  a  little  lower,  exactly  above  Scarpa's  triangle  and  separated  from 
it  by  the  crural  arch,  appears  an  induration  in  the  form  of  a  plaque, 
or  like  a  breastplate,  which  is  the  indication  of  the  invasion  of  the 
subcutaneous  cellular  tissue.  At  tliis  time,  the  tumor  has  often 
passed  the  Hmits  of  the  pelvis  to  project  into  the  iliac  fossa.  The 
plaque  extends,  softens  at  the  center,  reddens,  and  the  thick,  greenish 
pus  flows  in  enormous  quantities,  often  by  a  very  small  opening. 
This  opening  may  be  made  by  the  vagina  and,  more  rarely,  by  the 
rectum,  the  caecum,  or  even  the  bladder.  Fatal  peritonitis  is  more 
frequently  due  to  the  extension  of  the  inflammation  than  to  its 
opening  into  the  great  serous  cavity.  The  opening  may  remain 
fi.stulous,  giving  issue  to  smaller  and  smaller  quantities  of  pus  and 
finally  closing  after  a  very  long  time ;  the  patients  often  succuml) 
at  this  period  to  hectic  fever,  if  the  surgeon  does  not  interfere  to 
open  freely,  drain  and  disinfect  the  pus  focus. 

The  diagnosis  can  only  be  doubtful  at  the  beginning,  when  it  is 
not  known  whether  the  suppuration  will  be  circumscribed,  confined 
to  a  pelvic  abscess,  or  at  the  end,  when  haraig  passed  the  pelvis,  it 
has  transformed  the  phlegmon  of  the  broad  hgament  into  a  true 
abscess  of  the  ihac  fossa.  It  is  then  by  the  study  of  its  course  that 
the  diagnosis  wiU  be  established ;  it  is,  however,  very  characteristic 
and  can  not  be  confounded  with  a  perityphlitis,  a  psoas  abscess  or 
especially  a  galloping  cancer  of  the  iliac  bone. 

IV. — Diffuse  pelvic  cellulitis  is  only  the  local  manifestation  of  a 
general  septicsemic  state,  which  is  alone  sufficient  to  attract  the 
attention  of  the  physician.  I  shall,  then,  not  dwell  upon  it.  I  will 
merely  mention  the  extreme  rapidity  of  its  extension,  which  has  been 
compared  to  that  of  erysipelas ;  the  tendency  to  necrosis  of  the 
cellular  tissue,  which  may  give  rise  to  emphysema ;  the  sometimes 
important  ulceration  of  the  vessels,  occasioning  formidable  haemor- 
rhages ;  the  fatal  progress  of  the  disease. 


Perimetrosalpingitis.  407 

Prognosis. — This  varies  essentially  according  to  the  forms  and 
the  degrees  of  the  perimetro-salpingitic  inflammation.  It  is  the 
fault  of  not.ha\'ing  made  this  distinction  that  authors  differ  so 
notably  on  this  question  of  prognosis. 

Serous  perimetro-salpingitis  partakes  of  the  prognosis  of  the  tubal 
lesion  involved.  It  has  a  chi-onic  course  with  relapses,  but  does  not 
imperil  life.  It  remains  for  a  long  time  as  an  infirmity  more  than 
a  disease. 

Pelvic  abscess  is  more  serious.  It  may  cause  death  by  acute 
peritonitis,  rapid  septicaemia,  or  by  slow  hectic  fever.  It  has  also 
a  capricious  course,  with  paroxysms  well  described  by  Gosselin. 
But  tliis  surgeon,  like  liis  contemporaries,  manifestly  confounds 
under  the  name  of  periuterine  iDlilegmon,  catarrhal  salpingitis  with 
inflammatory  cedema  and  pyosalpinx. 

When  the  patient  has  escaped  acute  accidents  and  the  disease, 
by  resorption  or  spontaneous  evacuation  of  the  abscess,  has  reached 
what  may  be  called  its  natural  cure,  the  patient  none  the  less 
remains  subject  to  incessant  disturbances  of  the  health  in  con- 
sequence of  the  clu'onic  lesions  of  the  tube,  and  also  of  abnormal 
adhesions,  ligamentary  retractions,  displacements  of  the  uterus  and 
ovary.  Sanger  has  expressly  noted  that  the  ureters  were  much  more 
easily  felt  m  a  woman  having  had  periuterine  inflammations,  as  if 
their  walls  were  thickened  by  the  neighboring  inflammatory  process. 
Accidents  of  pyelo-nephritis  even  have  been  reported,  caused  by 
cicatricial  retraction  resulting  from  a  pelvic  abscess. 

Freund  has  described  under  the  name  "cln-onic  atrophic  para- 
metritis "  a  disease  which  may  frequently  be  due  to  a  pehdc  abscess 
cured  by  spontaneous  absorption  and  subsequent  induration  of  the 
tissues  affected  by  the  inflammation.  Under  the  influence  of  this 
retraction  the  vessels  are  compressed  and  there  results  an  atrophy 
of  the  whole  genital  canal  with  anticipated  menopause. 

Phlegmon  of  the  broad  ligament  is  serious.    Death  may  suddenly 
come  at  the  beginning  of  the  mflammatory  distiirbance,  or  later  by  ' 
the  length  of  the  suppuration,  or  even  unexpectedly  by  embolism 
succeeding  to  thrombosis  of  the  veins  of  the  pelvis. 

Diffuse  pelvic  cellulitis  is  almost  certainly  fatal. 

Treatment. — The  treatment  of  perimetro-salpingitis  is  associated 
with  that  of  the  salpingitis  which  produces  it.  It  especially  con- 
sists in  rest,  revulsives,  and  prolonged  injections  of  hot  water. 
These  are  the  cases  which  yield  quickly  to  electricity.  Such  acute 
exacerbations  are  often  seen  to  disappear  rapidly  in  consequence 
of  an  energetic  intrauterine  treatment,  curetting  and  injections,  and 
this  result  has  been  called  to  the  support  of  the  lymphatic  origin  of 
the  perimetritic  accidents.  These  incessant  acute  exacerbations 
are  not  the  least  of  the  indications  which  have  led  the  surgeon  to 
the  extirpation  of  the  appendages,  a  cure  at  once  of  the  salpingitis 


408  Pcrimriro-Salphifiitig. 

and  of  the  perisalpingitis.  The  tumors  of  acute  inflammatory 
oedema  have  no  tendency  to  suppurate,  and  as  they  are  the  most 
frequent  they  have  given  support  to  the  expectant  plan  of  treatment 
which  has  been  too  widely  applied.  I  utterly  reject  punctures  for 
the  purpose  of  evacuating  the  serous  collections,  they  may  cause 
suppuration  and  they  scarcely  hasten  their  resolution. 

For  the  other  forms,  pelvic  abscess,  abscess  of  the  broad  ligament, 
the  principal  mdication  is  first  to  modifj'  the  intensity  of  the  inflam- 
mation by  prolonged  hot  douches,  local  bleeding,  etc.  Finally,  as 
soon  as  pus  is  formed  it  should  be  sought  at  once,  for  as  BriekeU 
declares,  "the  surgeon  should  not  tolerate  the  presence  of  pus  in 
any  part  of  the  body."  The  systematic  abstention  prescribed  by 
Becquerel,  Aran,  West,  de  Sinety,  Siredey  and  Danlos,  etc.,  is 
losing  more  and  more  of  its  partisans.  In  what  region  is  it  neces- 
sary to  open  the  purulent  collection  and  how  should  the  opening  be 
made  ?    I  shall  consider  in  order  the  different  classes  of  cases. 

A.  Abscess  jjointliHi  toward  the  ragiiia. — Is  puncture  with  the 
trocar  sufficient?  It  has  been  advised  by  Simpson  and  recently 
taken  up  by  Teuueson,  who  makes  it  in  the  posterior  vaginal  cul- 
de-sac,  even  in  the  absence  of  fli;ctuation.  He  employs  capillary 
puncture  with  aspu'ation  to  evacuate  either  the  seiiim  or  the  pus. 
This  method  has  Httle  to  recommend  it,  it  is  dangerous  and  is  liable 
to  wound  the  intestine  if  the  sac  is  stiU  remote  from  the  vaginal 
waU,  and  it  is  insufficient  if  the  sac  is  adherent.  It  may  be 
employed,  however,  in  this  latter  case  as  a  means  of  ensuring 
diagnosis  and  as  a  preliminary  to  more  effective  interference. 
Professor  Laroyeune  also  makes  the  punctm-e  thi-ough  the  vagina 
into  the  mass  of  the  chronic  periuterine  inflammation  with  latent 
effusions  of  a  purulent,  serous  or  sanguineous  nature.  His  special 
trocar  (the  size  of  No.  20  sound)  opens  laterally  by  a  slit,  permitting 
after  puncture  the  introduction  of  a  lithotome  which  makes  a 
lateral  incision  of  thi-ee  to  five  centimetres.  A  glass  tube  with  an 
olive-shaped  extremity  is  then  introduced  and  serves  for  antiseptic 
douching  under  a  light  pressure.  He  has  obtained  some  success 
by  this  metliod. 

I  believe  that  this  technique  can  be  simplified,  after  having 
recognized  the  presence  of  pus,  by  puncture  with  an  aspirator,  by 
incising  the  posterior  vaginal  cul-de-sac  layer  by  layer  and  arresting 
the  haemorrhage  by  haemostatic  suture,  placed  as  in  the  first  stage 
of  vaginal  hysterectomy.  Slight  oozing  of  blood,  may  be  overcome 
])y  a  tampon.  After  opening  the  abscess,  a  cruciform  drainage 
tube  is  placed  in  it  and  lightly  packed  around  vdth  iodoform  gauze. 
This  is  very  nearly  the  procedure  Munde  uses.  He  adds  a  very 
careful  cleansing  of  the  abscess  \\-ith  the  blunt  curette,  which  it 
appears  to  me  is  useful  only  in  exceptional  cases.  This  curetting 
is  not  without  danger.     Laroyeune  has  shown  that  the  superior 


Perimetro-SalphitiUk.  10& 

wall  of  the  pelvic  abscess  is  generally  friable  and  may  even  be  torn 
by  injections  that  are  a  little  too  forcible.  To  avoid  wounding  the 
ureters,  the  following  rules  should  be  observed  in  the  choice  of  an  in- 
cision :  Posterior  tumor. — Transverse  or  vertical  incision,  directed 
in  line  with  the  long  axis  of  the  tumor.  Lateral  tumor. — Oblique 
incision,  backward  and  outward,  not  passing  farther  forward  than 
the  prolongation  of  the  transverse  diameter  of  the  cervix.  Anterior 
tumor.  Very  small  transverse  incision  combined  with  a  larger 
antero-posterior  incision.  I  believe  that  the  incision  through  the 
vagina  should  be  reserved  for  a  small  number  of  particularly  favor- 
able cases,  and  that  for  general  use  it  is  infinitely  inferior  to 
laparotomy.  In  fact,  it  is  only  after  direct  exploration,  after  open- 
ing the  abdomen,  that  we  can  be  sure  it  is  not  possible  to  extirpate 
the  sac,  the  treatment  which  cures  absolutely,jwhile  incision  leaves 
a  focus  for  renewed  attacks.  Finally,  in  the  vaginal  incision,  we 
cannot  be  wholly  secure  against  the  danger  of  wounding  intestinal 
loops  adherent  in  Douglas'  cul-de-sac. 

B.  Abscess  pointing  toward  the  rectum. — Should  we  incise  through 
the  rectum  ?  In  view  of  the  difficulty  of  antiseptic  after-treatment, 
I  do  not  think  so,  notwithstanding  the  inordinate  endorsement  of 
this  method  by  Byford.  In  such  cases  the  pus  should,  by  preference, 
be  evacuated  by  a  parasacral  incision  or  by  perineotomy. 

C.  The  abscess  is  equally  distant  from  the  vagina  and  from  the  ah- 
dominal  tvall.  —  Various  ways  of  reaching  it  have  been  proposed: 
1.  Perinseal  opening  (Hegar,  Sanger,  0.  Zuckerkandl).  2.  Pelvic 
opening  (E.  Zuckerkandl,  Wiedow,  Sanger).  3.  Incision  above 
Pouprat's  ligament  and  detachment  of  the  peritonaeum  to  the  situ- 
ation of  the  abscess  (Hegar)  by  an  operation  analogous  to  that  for 
ligation  of  the  iliac,  and  that  I  propose  to  call  subperitonaeal  lapa- 
rotomy. 4.  Laparotomy,  properly  so-called,  or  transperitonaeal 
laparotomy,  especially  advised  by  Lawson  Tait ;  this  comprises  two 
steps,  suture  of  the  walls  of  the  abscess  to  the  abdomen,  or  resection 
reducing  the  cavity  as  much  as  possible  and  drainage  through  the 
vagina  (Martin).  5.  Incision  in  two  sittings.  I  shall  review  these 
procedures  rapidly. 

1.  Perinceal  opening.- — A  long  time  ago  Hegar  proposed  to  seek  the 
abscess  by  an  incision  from  the  tuberosity  of  the  ischium  to  the 
point  of  the  coccyx.  The  vertical  perineotomy  which  Sanger  has 
recommended  is  only  an  extension  of  Hegar's  incision.  It  consists 
of  an  incision  one  side  of  the  median  line  commencing  at  the  posterior 
third  of  the  major  lip  of  the  vulva  and  terminating  at  two  centi- 
metres outward  from  the  anus,  between  this  orifice  and  the  tuberosity 
of  the  ischium.  The  abscess  is  reached  by  incising  the  levator  ani 
above  (Fig.  219).  The  transverse  perineotomy  of  Otto  Zuckerkandl 
has  been  especially  recommended  for  extirpation  of  cancer  of  the 
uterus,  but  it  has  also  been  mentioned  (Sanger)  as  serving  for  evac- 


410 


Prrinu'tri>-S(d})i  Ill/it  l-i. 


nation  of  coUection«  situated  in  Douglas'  c-ul-de-sac.  The  incision 
extends  from  one  iscliium  to  the  other,  its  two  extremities  being 
prolonged  a  little  obliquely  from  before  backward,  and  fi-om  within 
outward.  Douglas'  cul-de-sac  is  thus  reached  and  the  abscess 
evacuated  mth  less  chance  of  infection  than  thi-ough  the  rectum . 
But,  as  the  wound  is  mfundibuliform  there  is  not  sufficient  room  for 
extirpation  of  a  pyosalpinx  iFip.  'i-ifl.) 


Fig.  2ig. — Vertical  perineotomy  (Hegar,  Sanger),     a,  anus;   T  i.  tuberosity  of  the 
Uchiuni ;  m  gf,  gluteus  maximus;  m  r a,  levator  ani ;  Fir,  ischia  rectal  fossa. 

2.  Pelvic  or  sacral  opeit'uifi. — Several  quite  new  methods  of  arriving 
at  the  abscess  have  been  proposed.  Among  these  are  the  para- 
sacral incision  of  E.  Zuckerkaudle  and  Wolfler,  and  the  definitive  or 
the  temporary  resection  of  the  coccy.x  and  of  the  sacrum,  according 
to  Kraske's  method  and  Hegar's  modification.  All  these  procedures 
are  ingenious  and  may  do  service  in  special  cases,  but  they  are 
inferior  to  laparotomy. 

3.  SabperitoiKeal  lajiarotomij  presents  the  great  advantage  of  set- 
ting aside  the  danger  from  etfusion  of  pus  into  the  serous  cavity. 
It  is  infinitely  more  benign,  in  such  cases,  than  laparotomy  properly 


Perimetro- Salpingitis. 


411 


so-called,  or  transperitonaeal  laparotomy.  But  it  has  the  disad- 
vantage of  only  permitting  an  incision  into  the  abscess  without 
the  possibility  of  extirpation,  in  conditions  where  the  sac  can  be 
enucleated,  although  adherent.  Thus,  I  am  less  favorably  disposed 
to  this  operation  since  our  knowledge  of  pyosalpinx  became  more 
exact.  This  operation  may,  however,  be  of  real  service  in  special 
cases.  I  shall,  therefore,  describe  it  briefly.  The  exact  connections 
of  the  abscess  must  first  be  ascertained  by  bimanual  exploration. 


Fig.  220. — Trausveise  perineotomy  (O.  Zuckerkandl ) 
vagina ;  M  r  a,  levator  ani ;  F  i  r,  iscliio- rectal  fossa. 


A,  anus ;    R,  rectum ;   V, 


There  are  incisions  of 
above  the  crural  arch, 
tonseal  ceUular  tissue. 
fingers,  as  in  ligature 
up  with  a  large  retrac 
operator,  carrying  the 
feel  the  resistance  of 
ligament  is  arrived  at 


eight  to  ten  centimetres  long  at  one  centimetre 
,  dividing  layer  by  layer  down  to  the  subperi- 
The  serous  membrane  is  detached  with  the 
of  the  external  iHac.  The  peritonaeum  is  held 
tor  or  by  the  fingers  of  an  assistant,  while  the 
finger  to  the  bottom  of  the  wound  attempts  to 
the  abscess.  Thus  the  base  of  the  broad 
by  degi-ees  in  the  deepest  part  of  the  pelvic 


412  Perimetrosalpingitis. 

cavity.  When  the  abscess  is  reached,  when  fluctuation  is  detached, 
it  is  incised,  its  cavity  cleansed  carefully  and  dramage  is  made 
either  through  the  abdominal  wall,  or  through  the  vagina  with  the 
cruciform  drainage-tulie. 

It  may  occur  that  the  detachment  of  the  peritonasum  may  not  be 
sufficient  to  allow  the  abscess  to  be  reached,  or  that  an  old  hiflam- 
mation  has  made  the  serosa  adherent  and  fi-iable.  Then  at  a  subse- 
quent sitting,  the  ingenious  procedure  adnsed  by  Hegar  may  be 
employed,  opening  in  two  sittings,  that  I  may  describe  later. 

4.  The  incision  by  transperitoniieal  laparotomy,  or  laparotomy 
proper,  was  first  made  by  Tait.  The  abdomen  is  opened  by  a  small 
incision  (seven  to  ten  centimetres),  the  fingers  are  introduced  to  seek 
the  tumor ;  it  is  evacuated  vrAh  an  aspirator  and  drawn  between  the 
lips  of  the  abdominal  wound.  Then  the  sac  is  carefully  cleansed, 
sutured  to  the  abdominal  walls,  and  packed  with  antiseptic  gauze 
after  placing  in  it  two  large  drainage  tubes.  Very  good  success  has 
been  obtained,  but  also  some  failures.  Great  difficulties  may  be 
met^^ith.  It  is  not  always  possible  to  di-aw  out  the  sac,  and  if  fixed 
to  the  abdominal  wall  with  difficulty,  it  may  rupture  and  give  rise 
to  a  septic  effusion  into  the  peritoneal  cavity.  We  may  proceed, 
if  possible,  in  the  following  manner,  after  being  assured  that  enucle- 
ation is  impossible,  and  in  the  rare  cases  where  the  walls  of  the  sac 
are  free ;  the  abscess  should  be  emptied  by  punctui'e,  the  peri- 
tonaeum being  perfectly  protected ;  the  sac  should  be  carefully 
cleansed ;  exploration  being  made,  at  the  same  time,  of  its  base  and 
of  the  posterior  vaginal  cul-de-sac,  the  possibUity  of  drainage  in 
this  direction  is  ascertained.  If  this  is  found  to  be  easy,  a  large 
trocar  or  Wolfler's  forceps  is  pushed  thi-ough  the  posterior  vaginal 
cul-de-sac  into  the  abscess  cavity  and  a  cruciform  ihfainage-tube 
placed  in  its  base  with  the  long  arm  in  the  vagina.  It  only  remains 
to  resect  as  much  of  the  pus  sac  as  possible  and  to  close  it  perfectly 
on  the  abdominal  side  with  catgut  sutures.  Thorough  toilet  of  the 
peritonseum  and  closure  of  the  abdominal  wound  completes  the 
operation  (Martin).  If  the  wall  of  the  abscess  does  not  form  a  dis- 
tinct sac,  that  is  adapted  to  tliis  procedure,  we  are  content  with  a 
very  scrupulous  cleansing  and  an  antiseptic  tampouuement  such  as 
has  been  described. 

.5.  Finally,  Hegar  has  proposed  the  opening  in  two  operations, 
such  as  Volkman  uses  for  hydatid  cysts  of  the  liver.  In  the  first 
«itting,  laparotomy  is  pex'formed  and  the  wound  tamponed  with 
iodoform  gauze  in  such  a  way  as  to  create  a  canal  reaching  from 
the  sac  to  the  abdominal  incision.  At  the  second  operation  the 
sac  is  incised,  after  four  or  five  days,  when  the  adhesions  are  quite 
strong.  This  method  can  be  used  in  opening  through  the  posterior 
vaginal  cul-de-sac. 

D.  The  abscess   is  near  the   abdominal  wall.     Search  for  pus 


Perimetrosalpingitis.  413 

should  then  be  made  by  an  incision  immediately  under  Poupart's 
ligament,  and,  if  it  is  necessary,  the  peritonaeum  detached  to  a 
small  extent.  It  is  necessary  to  remark,  besides,  that  even  a  button 
hole  in  the  serous  membrane,  made  when  the  purulent  pocket  is 
large  and  near  the  integument,  is  of  but  little  importance,  for  the 
intra-abdommal  pressure  pushes  the  pocket  between  the  lips  of  the 
incision  and  maintains  it  there  in  such  a  manner  that  leakage  of 
pus  into  the  peritonaeum  need  scarcely  be  feared.  Subperitonseal 
laparotomy  must  not  be  confounded  with  incision  for  a  collection 
situated  in  the  iliac  fossse,  accompanied  with  very  limited  detach- 
ment of  the  peritonaeum,  but  without  the  deep  exploration  in  the 
pelvic  cavity.  Some  authors  have  committed  this  mistake.  The 
incision  into  such  a  vast  purulent  collection,  as  a  phlegmon  of  the 
broad  ligament  generally  is,  should  be  sufficiently  large  (six  to  eight 
centimetres)  and  should  be  kept  open  by  the  use  of  two  large 
drainage  tubes,  fastened  together,  like  the  barrels  of  a  gun,  and 
pushed  carefully  into  the  depth  of  the  abscess.  They  can  be  replaced 
by  a  thick  strip  of  iodoform  gauze.  If  injections  are  used,  they  should 
be  made  with  a  weak  antiseptic  solution  (carbolic  solution,  10-1000 ; 
sublimate,  1-5000)  and  should  always  be  terminated  by  an  injection 
of  filtered  and  boiled  water,  to  avoid  having  in  the  cavity  a  liquid 
which  may  give  rise  to  poisoning  by  its  absorption.  If  stagnation 
of  pus  is  observed  this  diverticulum  of  the  abscess  may  be  tamponed 
with  iodoform  gauze.  Finally,  if  the  abscess  extends  to  quite  near 
the  vaginal  cul-de-sac,  as  recognized  by  bimanual  exploration, 
drainage  may  be  made  in  this  direction.  But  it  is  necessary  to 
take  great  care  not  to  wound  the  bladder,  by  guiding  the  trocar  with 
the  finger. 

The  residual  products  of  old  inflammations  surrounding  the 
tubes,  false  membranes,  adhesions,  etc.,  give  rise  to  complex  j)ain- 
ful  symptoms,  by  the  pressure  they  exert  on  the  tubes  and  ovaries, 
by  the  uterine  deviations  that  they  cause,  by  the  agglutination  of  the 
intestines  and  the  omentum  to  the  pubes,  the  pressure  upon  the 
ureters,  etc.  It  is  in  these  special  cases  that  massage  is  advanta- 
geous to  favor  the  resorption  of  the  plastic  products.  When  there 
is  a  predominenee  of  the  painful  element,  and  when  it  assume  a 
neuralgic  character,  the  Faradic  current  may  give  good  results.  It 
has  been  proposed,  as  I  have  indicated  before,  to  perform  laparotomy 
for  the  single  purpose  of  liberating  the  prolapsed  and  compressed 
organs,  by  destroying  the  adhesions  ^'ithout  removing  the  ap- 
pendages. The  good  results  thus  obtained,  without  the  absolute 
efficacy  of  these  incomplete  operations,  show  at  least  the  large  part- 
that  it  is  necessary  to  attribute  to  this  pathological  element  in  the 
interpretation  of  morbid  symptoms. 

Another  remote  result  of  the  inflammations  arising  about  the 
uterine  apendages  is  the  modification  of  the  resistance  of  the  broad 


414  Perimetro-Sdl/pingitis. 

ligaments,  of  the  round  ligaments  and  of  the  utero-saeral  ligaments. 
Our  knowledge  on  tliis  subject  is  very  limited,  and  the  deductions 
drawn  from  these  lesions  are  rather  theoretical  than  actually  proven. 
It  is  not  the  less  certain  that  the  uterine  deviations  should  often  be 
attributed  to  the  relaxations  or  to  the  contractions  of  the  ligaments 
that  are  the  results  of  former  inflammations.  I  will  note,  in  par- 
ticular, the  retraction  of  the  broad  ligament  that  is  so  frequently 
observed  in  a  deep  laceration  of  the  cervix  of  the  same  side,  and 
which  produces  a  certain  degree  of  lateral  deviation  of  the  uterus, 
by  virtue  of  a  true  chi'onic  parametritis.  This  is  perhaps  only  a 
cloronic  perilymphangitis,  a  sclerosis  of  the  connective  tissue  of  the 
broad  ligament  around  the  numerous  lymphatic  trunks  which  ramify 
at  its  base,  and  which  coming  from  the  cei"vix  pass  to  the  ilia-c 
ganglia.     Here,  again,  massage  may  render  actual  service. 

It  is  in  consequence  of  an  homonymy  which  establishes,  I  believe, 
a  forced  relation  between  the  true  condition  that  I  speak  of  in  the 
chapter  on  parametritis  of  a  lesion  described  by  Freund  under  the 
term  chronic  atrophic  parametritis.  Among  young  women  it  is 
sometimes  found  that  the  sexual  organs  are  thus  reduced  in  size 
until  they  are  smaller  than  after  the  menopause ;  the  broad  hga- 
ments  are  retracted  and  hard.  This  will  be,  then,  an  extension  of 
atrophy  of  the  uterus  to  the  contiguous  tissues.  For  treatment, 
Freund  recommends  hot  douches  and  massage. 


Ch'arian  Cysts.  415 


CHAPTER  XXX. 


PATHOLOGICAL  ANATOMY  OF   OVARIAN 
CYSTS. 

In  an  histogenetic  point  of  view,  tumors  of  tiie  ovary  have  been 
divided  into  neoplasms  of  connective-tissue  origin  and  neoplasms 
of  epithelial  origin.  The  first  group,  desmoid  tumors,  comprises 
the  fibromata,  the  sarcomata,  the  myxomata,  aU  very  rare  growths, 
especially  the  last.  The  second  group,  epithelial  tumors,  includes 
the  cystomata,  the  carcinomata,  or  alveolar  epitheliomata,  and  the 
adenomata,  or  mucoid  epitheliomata.  In  a  clinical  point  of  view, 
the  best  division  is  that  which  distinguishes  solid  and  cystic  tumors. 
The  latter,  being  the  most  frequent,  deserves  our  first  attention. 

Pathological  anatomy  of  cysts  of  the  ovary. — Any  part  of  the  tubo- 
ovaiian  apparatus  may  be  the  point  of  origin  of  cystic  formations, 
the  cortical  poiiion  and  the  medullary  portion  or  parenchyma,  the 
inferior  border  or  the  hilum,  the  region  comprised  between  the  tube 
and  the  ovary  where  are  disseminated  vestiges  of  the  Wolffian  body. 
Essentially  distinct,  in  an  histological  and  anatomical  point  of  view, 
these  various  neoplasms  may  sometimes  be  artificially  arranged  in 
the  same  clinical  species ;  thus,  to  cite  an  example,  the  single  fact 
that  a  cyst  is  included  in  the  broad  ligament  is  sufiicient  to  consti- 
tute a  well-defined  surgical  class,  wliile  this  cyst  might  have  its 
origin  in  tliis  place  (unilocular  cyst  with  limpid  contents),  or  pro- 
ceed from  the  hilum  of  the  ovary  (papillary  cyst),  or  from  the 
parenchyma  of  the  ovary  (glandular  cyst)  and  be  introduced  between 
the  layers  of  the  broad  ligament  by  separating  them. 

For  convenience  of  description,  it  is  important  to  distinguish 
cystic  productions  according  to  the  volume  that  they  acquire. 
There  are  some,  in  fact,  which  never  pass  a  medium  size  and  may 
be  tolerated,  as  they  may  give  rise  only  to  some  painful  troubles, 
■without  compromising  existence.  Others,  on  the  contrary,  develop 
with  very  great  rapidity  from  the  time  that  their  growth  becomes 
progressive.     I  will  thus  divide  cysts  of  the  ovary  into : 

f     I.   Proliferous,  or  glandular  proliferous  cysts. 
I    II.  Proliferous,  or  papillary  proliferous  cysts. 
Cysts  of  great  development.  \  III.  Dermoid  cysts,  simple  or  mixed. 

I   IV.  Parovarian  cysts,  comprising  different  varieties; 
[  hyaline,  papillary,  dermoid. 

\     I.   Small  residual  cysts  (from  the  hydatids 
of  Morgagni,   from    the    horizontal 
Cysts  of  medium  development.  \  canal  of  the  parovarium). 

I    II.  Follicular  cysts. 
(^  III.  Cysts  of  the  corpus  luteum. 


416 


Ovarian  Cysts. 


Finally  ovarian  cysts  may  contract  anatomical  relations  with  the 
tube  and  constitute  a  distinct  variety ;  these  are  tubo-ovariau  cysts. 


Fig.  221. — Vertical  section  of  the  ovary  of  a  bitch  (Wyder). 


Cysts  of  great  development. — I.  and  II.  Proliferous  cysts. — The 
appearance  of  these  tumors  is  quite  variable.  However,  some 
common  characteristics  permit  description  together,  to  ■which  I  wiU 
add  finally  the  special  details  of  each  variety.  Both  ovaries  may 
be  invaded,  hut  the  lesions  then  have  not  the  same  degree  of 
development.  Thus,  while  one  side  is  occupied  by  an  enormous 
tumor,  the  other  is  sometimes  the  seat  of  beginning  changes  which 
scarcely  affect  its  volume.  The  surgeon  should  never  forget  to 
inspect  the  ovary  of  the  supposed  healthy  side  before  closing  the 
abdomen.  The  volume  may  be  such  that  the  entire  abdomen  is 
filled,  the  costal  cartilages  being  pushed  outward.  The  form  is 
markedly  spherical  or  ovoid,  but  with  projections  at  the  weak  points, 
which  have  given  wiiy  before  the  distention  more  than  the  rest  of 
the  tumor.  In  the  portions  where  the  wall  is  thicker,  the  color  is 
pearly-wliite  or  bluish,  marbled  by  the  venous  vessels.  In  the 
thinner  portions,  the  color  is  violaceous,  greenish,  or  blackish, 
according  to  the  nature  of  the  contents.  The  external  surface, 
smooth  and  slippery,  is  sometimes  strewn  with  small  papillary 


Ovarian  Cysts. 


417 


vegetations  resembling  either  the  frog-spawn  or  the  vegetations  of 
some  mucous  plaques.  A  narrowed  portion,  or  pedicle,  generally 
supports  the  tumor. 


Fig.  222. — Schemaof  the  tuboovarian  apparatus  (Doran).  la,  multilocular  glandu- 
lar cyst  developed  in  i,  ovarian  parenchyma;  3,  papillary  cyst  developed  in  2,  tissue 
of  the  hilum  of  the  ovary;  4,  unilocular  cyst  of  the  broad  ligament  independent  of  the 
parovarium  10:  5,  unilocular  cyst  of  the  broad  ligament  situated  above  the  tube,  but 
not  united  vi^ith  it;  6,  similar  cyst  near  7,  tubo-ovarian  ligament;  8,  hydatid  of  Mor- 
gagni  which  is  never  the  origin  of  a  large  cyst;  9,  cyst  developed  at  the  expense  of 
the  horizontal  canal  of  the  parovarium ;  11,  cyst  developed  at  the  expense  of  the  verti- 
cal tube;  these  are  the  cysts  which,  according  to  Doran,  constitute  the  papillary  cyst 
of  the  broad  ligament;  12  13,  Gartner's  canal  obliterated;  papillary  cysts  may  develop 
along  this  obliterated  canal  (Coblenz)  and  would  be  the  origin  of  papillary  cysts  in 
connection  with  the  uterus  13, 


Fig.  223. — Proliferous  glandular  cyst  of  the  ovary,  of  areola  aspect. 

The  interior  conformation  varies  as  to  the  number  of  sacs  and 
theu"  contents.  Cruveilhier  divides  the  cysts  into  unilocular,  multi- 
locular, areolar  and  compound,  but  this  division  does  not  deserve 


418 


Ovarian  Cr/stH. 


to  be  retained.  It  is  useful,  however,  for  the  purposes  of  description, 
to  preserve  the  words,  areolar,  unilocular,  multiloc-ular.  We  know 
that  the  first  are  due  to  the  destruction  of  the  intermediary  septa, 
the  vestiges  of  which  are  found  as  spurs  or  trabecule.  One  sac  is 
generally  pre-eminent ;  sometimes  there  are  two  or  three  of  similar 
size ;  aside  from  cavities  of  a  capacity  of  several  liti'es,  there  are 
found,  then,  small  cysts  of  the  size  of  an  orange  or  of  a  nut.  Even 
in  certain  points,  all  of  a  portion  or  the  tumor  may  be  formed  by 
an  agglomeration  of  very  small  cavities  separated  by  a  more  or 
less  dense  tissue,  sometimes  gelatinaform,  giving  the  section  an 
areolar  appearance.  In  cysts  that  are  apparently  unilocular,  and 
which  are  surgically  so-called,  the  anatomist  almost  always  dis- 
covers in  the  thickness  of  the  waU  a  number  of  secondary  cavities. 


Fig.  224.— .Small,  proliferous  glandular  cyst,  muhilocular  (Dnran). 


The  sac  of  the  cyst  can  often  be  separated  into  three  distinct 
layers,  principally  at  the  pedicle.  The  external  is  fibrous,  the 
middle  consists  of  a  connective  tissue  framework  and  the  third  is 
fonned  by  a  capillary  plexus  which  is  covered  with  epithelium. 
The  veins,  which  are  very  large,  may  equal  the  volume  of  the 
femoral  or  even  the  vena  cava.  Thej'  ramify  over  the  external 
surface  and  are  adherent  hke  sinuses,  thus  making  a  wound  danger- 
ous. Sometimes  large  bands  of  non-striated  muscular  tissue  are 
spread  out  on  the  tumor  near  the  pedicle.  The  epithelium  -which 
covers  the  external  surface  is  cubical,  different  fi-om  the  flat  peri- 
tonasal  epithehum. 

The  internal  surface  of  the  cysts  are  lined  with  a  cylindrical 
epithelium,  very  short,  which  Waldeyer  has  described  as  one  layer 
and  Eindfleish  as  several.  Malassez  and  de  Sinety  have  insisted 
on  its  polymorphism.  They  have  described  a  subepithelial  endothe- 
lial layer  and  have  sho^vn  that  in  the  same  type  of  cyst,  the  most 


Ovarian  Cifsts. 


419 


diverse  forms  of  epithelium  may  be  met,  deformed  and  superposed. 
They  have  shown  the  importance  of  the  calciform  cells  with  regard 
to  the  viscosity  of  the  liquid.  Finally,  they  have  established  a 
relation  between  the  cells  derived  from  the  normal  type  that  are 
met  in  cysts,  or  metatyi^ical  epithelium  and  that  of  the  glandular 
epithelioma  of  the  breast. 


Fig.  225. — Proliferous  glandular  cyst  of  the  ovary  (WyderV 

On  section  of  the  wall,  there  are  found  depressions  in  the  epithe- 
lial covering,  producing  the  appearance  of  acinous  glands.  There 
are  also  found,  on  the  internal  surface,  some  vegetating  cysts 
formed  by  a  proliferation  of  the  stroma,  of  a  type  recalling  the 
myxomata  or  the  fibro-sareomata.  They  are  covered  by  a  single 
layer  of  epithelium  and  assume  a  dendritic  appearance.  Some- 
times epithelial  prolongations  of  tubular  form  penetrate  them 
and  give  to  the  section  a  carcinomatous  appearance.  Small  cysts 
may  develop  in  these  papillae.  In  spite  of  the  hybrid  forms  which 
may  thus  frequently  occur,  it  is  useful  to  distinguish,  with  Waldeyer, 
neoplasms  in  which  the  principal  vegetation  proceeds  from  the 
epithelium  and  terminates  in  the  formation  of  glandular  tubes 
(proliferous  glandular  cyst)  and  those  in  which  it  is  especially  the 
connective  tissue  of  the  cyst  wall  that  develops  and  projects  under 
the  form  of  vegetations  in  the  interior  (proliferous  papillary  cyst). 
Certainly,  this  depends  very  much  upon  the  same  process  of  pro- 
liferation in  both  cases,  in  the  depth  of  the  tissue  in  one,  at  the 


420  Ovarian  Cysts. 

Burface  in  the  other :  but  the  physiognomy  of  the  neoplasm  under- 
goes a  considerable  change  according  as  it  is  the  vitality  of  the 
epithelial  element  or  that  of  the  connective  tissue  element  which 
predominates.  There  also  exist  mixed  forms  of  cysts,  both  papil- 
lary and  glandular. 

The  glandular  proliferous  cyst  is  characterized  by  the  abundance 
of  small  glands  in  the  wall  of  the  cyst.  The  glancular  tubes  are 
transformed  into  cysts  by  the  following  process :  then-  orifices  be- 
come obUterated ;  the  opposite  extremity,  infundibuliform,  is  then 
dilated  and  gives  rise  to  other  glandular  tubes  which,  in  theii-  tum^ 
pass  thi'ough  a  cystic  stage  to  end  in  a  new  generation  of  glajids. 
The  multiplication  may  thus  go  on  indefinitely. 

The  papillary  prohferous  cyst  presents  the  marks  of  a  predomi- 
nating connective  tissue  formation ;  the  connective  tissue  forms 
granulations  which  project  into  the  cystic  cavity  by  pushing  out 
the  epithelium  and  dividing  it  into  loose  papilliform  ramusculi. 
These  dentritic  excrescences  may  fill  and  distend  the  cyst  to  the 
point  of  rupture  and  then  project  externally  through  a  narrow  or 
through  a  large  laceration.  Then  the  cyst  may,  so  to  speak,  turn 
on  itself,  its  aspect  being  completely  changed  by  its  convex  fundus 
becoming  sti-etched  by  granulations.  At  the  same  time  the  pro- 
ducts of  secretion  fall  into  the  peritonseal  cavity  and  induce  ascites 
and  the  metastatic  production  of  disseminated  papillary  masses. 
Tumors  of  this  origin  have  often  been  described  as  superficial  papil- 
lomata  of  the  ovary,  while  they  owe  their  origin  to  previous  cyst, 
the  dehiscence  of  which  has  caused  its  disappearance.  However, 
Tegetations  may,  in  appearance,  arise  directly  from  the  sui-face  of 
the  ovary.  Prochaska,  Gusserow,  Eberth,  Bii'ch-Hirschfeld,  Mar- 
chand  and  Coblenz  have  cited  examples.  But  the  facts  of  these 
cases  really  deserve  description  with  the  dehiscent  cysts  and  the 
two  obsei'vatious  of  Coblenz  clearly  show  this  parentage. 

Papillary  cysts  are  very  often  included  in  the  broad  Ugament, 
for  they  arise  either  in  the  remnants  of  the  Wolfliau  body,  or  in  the 
hilum  of  the  ovary.  Thus,  arising  fi-om  the  adherent  border  of  the 
ovary,  the  tiimor  is  naturally  brought  between  the  folds  of  the  broad 
ligament  by  its  development.  Here  it  gives  rise  to  the  phenomena 
of  compression  that  are  the  accompaniment  of  all  intra-ligameutous 
tumors.  The  perforation  of  the  tumor  by  the  papillary  vegetatioub 
that  it  encloses  may  be  made  not  only  toward  the  peritonaeal 
cavity  but  also  toward  the  deeper  parts  and  cause  intimate  adhesions 
of  the  cyst  to  the  pelvis,  to  the  bladder,  to  the  rectum  and  to  the 
uterus.  It  is  not  rare  to  observe  calcareous  grains  in  the  papillaiy 
masses.  These  bodies  present  a  certain  similarity  to  the  deposits 
of  Ume  that  are  observed  in  some  placentas. 

The  mode  of  genesis  of  proliferatous  cysts  of  the  ovary  (glandular 
and  papillary'*  has  given  rise  to  very  numerous  controversies  that 


Ovarian  Cysts.  421 

have  not  yet  been  settled.  The  old  hydatid  theory  was  replaced  m 
1807  by  Meckel's  theory  of  dropsy  of  the  Graffian follicle.  Huguier 
and  Bauchet  then  imposed  some  restrictions  accepting  the  follicular 
theory  only  for  the  simple  cysts,  unilocular  or  multilocular.  For 
the  more  complex  forms  a  neoformation  is  admitted,  with  areolar 
or  colloid  degeneration  of  the  ovary,  according  to  Cruveilhier,  Vir- 
chow  and  Rokitansky.  The  stroma  and  its  colloid  degeneration 
then  play  the  principal  role  and  the  epithelial  element  is  quite 
neglected  in  the  works  of  Eindtleish  and  Mayweg.  Klebs  and  Wal- 
deyer  have  been  the  principal  advocates  of  the  rehabilitation  of  the 
role  of  the  epithelium  in  the  genesis  of  proliferous  cysts.  I  will 
briefly  state  the  theory  of  Waldeyer  as  it  is  accepted  to-day  by  a 
great  number  of  authors.  It  is  known  that  the  embryonal  ovary 
contains  a  very  large  quantity  of  epithelial  tubes,  derived  from  the 
germinal  epithelium  which  covers  the  surface  of  the  ovary.  These 
tubes,  the  tubes  of  Pfluger,  should  later  divide  and  become  occluded 
to  form  the  Graffian  foUicles,  a  product  of  secondary  evolution.  In 
the  new-born  these  tubes  are  still  found  and  perhaps  they  may 
exist  abnormally,  or  even  be  formed  by  heterochronia,  in  the  adult. 
Their  persistence  at  an  advanced  age  can  not  be  doubted  and  Slav- 
jansky  has  found  them  slightly  cystic  in  the  ovary  of  a  woman  of 
thirty  years.  These  tubes  may  exceptionally  be  transformed  into 
cysts  before  puberty,  and  they  have  been  found  in  the  new-born 
the  size  of  a  nut,  only  enlarging  after  puberty.  We  can  then  say 
that  not  only  have  all  cysts  of  the  ovary  a  congenital  origin,  but 
many  of  them  are  of  congenital  date  and  may  either  remain  station- 
ary or  develop  sooner  or  later. 

When  a  cyst  is  formed  at  the  expense  of  the  Pfluger's  tubes  the 
central  cells  soften  and  liquify,  and  the  walls  of  the  tubes  dilate, 
vegetate,  and  give  rise  by  granulations  to  new  tubes.  This  more 
complex  ulterior  cyst  is  always  composed  at  the  beginning  of  a 
simple,  small,  connective-tissue  sac,  lined  with  epithelium,  which  is 
only  the  primitive  glandular  epithelium,  in  part  liquified  to  form 
the  contents  of  the  cyst.  The  fusion  of  these  primary  cysts  finally 
constitute  the  enormous  cavities.  Every  unilocular  cyst  began  as  a 
multilocular  tumor  (Waldeyer).  I  have  already  shown  how  the 
ulterior  vegetation  of  the  waUs  gives  rise  to  the  papillary  projections, 
that  give  name  to  an  important  variety  of  cysts  of  the  ovary. 

Malassez  and  Sinety  do  not  admit  the  preponderant  role  at- 
tributed by  Waldeyer  to  Pfluger's  tubes.  They  believe  that  the 
germinal  epithelium  of  the  surface  of  the  ovary  is  the  true  matricular 
tissue  of  the  neoplasm,  and  that  the  process  begins  by  epithehal  in- 
vaginations. But  this  epithelial  neoformation,  which  in  the  physi- 
ological state  ends  in  the  construction  of  Pfluger's  tube  and  then  in 
the  Graafian  follicles,  is  engaged  in  a  less  specialized  direction  and 
onlj'  terminates  in  a  common  type  of  lining  epithelium,  gi-^ang  rise 


'12'2 


Ovarian  Cysts. 


to  tubes  dr  to  more  or  less  spherical  canties,  which  have,  according 
to  these  authors,  only  a  vague  resemblance  to  Pfluger's  tubes  and 
the  follicles.  Struck  by  the  resemblance  which  exists  between  these 
tumors  aud  the  covering  of  nonnal  mucous  membranes,  Malassez 
has  proposed  the  term  mucoid  epithelioma.  This  term,  though 
exact  in  au  histological  point  of  view,  gives  rise  to  some  confusion 
in  clinical  language,  where  the  word  epithelioma  carries  by  common 
usage  a  significance  of  malignity.  I  shall  say  the  same  of  the  term 
cysto-epithelioma,  adopted  by  some  authors.  The  designation 
proliferous  i-vsts  niipe;Hs  preferal)le. 


Fig.  226. — Papillary  cyst  of  the  ovan'  (Wyder). 

Have  the  papillary  cysts  an  histogenesis  different  fi-om  glandular 
cysts  •?  In  1877  Olshausen  suggested  the  hypothesis  that  they  came 
from  the  parovarium,  after  Waldeyer's  demonstration  that  this 
structure  penetrated  into  the  hilum  of  the  ovary.  The  reasons 
invoked  were  the  presence  of  cylindrical  epithelium  and  the  fre- 
quence of  the  inclusion  of  the  cysts  in  the  broad  Hgament.  Fischel 
afterward  developed  this  opinion,  and  pretended  that  these  tumoi-s 
contained  some  cells  of  the  gi-anular  membrane,  which,  according  to 
him,  certainly  came  from  the  Wolffian  body.  In  spite  of  the  sup- 
port that  Doran  has  given  this  view,  by  sho'wing  specimens  where 
the  ovary  was  preserved  by  the  side  of  the  papillary  cyst  arising 
from  the  hilum  (Fig.  227),  we  can  not  accept  it  to-day  -without 
reserve.     In  fact,  Marchand  and  Flaischlen  ha%e  shown  that  the 


Ovarian  Cysts. 


423 


beginning  of  the  cyst  may  occiir  at  the  surface  of  the  ovary,  and 
that  they  contain  then  ciliated  epithelium  in  continuity  with  the 
germinal  epitheHum.  According  to  Marchand's  observation,  it  is 
also  very  easy  to  understand  that  the  ciliated  epithelium  of  the 
papillary  cysts  may  be  derived  pathologically  from  the  germinal 
epithelium  since  this  filiation  takes  place  normally  for  the  epi- 
thelium of  the  Fallopian  tubes.  With  regard  to  the  papillary 
structure,  it  is  also  found  in  the  mucosa  of  the  tubes  and  it  is  not 
surprising  that  a  parallel  disposition  takes  place  in  a  morbid 
condition  in  similar  tissues.  Then,  in  brief,  the  germinal  epi- 
thelium will  be  the  point  of  departure  for  papillary  cysts  as  well  as 
for  glandular  cysts.  This  similarity  of  origin,  it  must  be  admitted, 
is  not  entirely  satisfactory.  How  shall  we  account,  then,  for  the 
profound  difference  which  separate  these  two  varieties  of  neoplasms, 
and  for  the  special  characters  of  the  papillary  neoproductions  ? 
How  shall  we  explain  their  frequent  bilateral  occurrence,  the  sub- 
serous inclusion,  and  their  malignity  ?  It  cannot  be  doubted  that 
this  point  still  calls  for  new  researches. 


Fig.  227. — Papillary  cyst  arising  in  the  hilum  of  the  ovary  (Doran). 


I  shall  study  at  the  same  time  the  liquid  contents  of  all  the 
proliferous  cysts,  although  it  differs  sensibly  according  to  the 
glandular  or  papillary  character  of  the  cavity,  it  must  not  be 
forgotten  that  cavities  of  both  kinds  may  be  seen  in  the  same 
tumor.  In  general,  the  liquid  in  large  cavities  is  thinner  than  that 
in  smaU  sacs.  Except  in  the  greater  part  of  parovarian  cysts, 
where  it  is  as  clear  as  spring  water  and  nonalbuminous  unless  from 
inflammation  or  sanguineous  effusion,  the  liquid  of  ovarian  cysts 
has  always  a  more  or  less  oily  consistence  to  the  touch ;  it  is  some- 
times sirupy.  The  color  varies  from  straw  color  or  apple  green,  to 
the  tint  of  coffee  or  chocolate ;  it  is  to  the  presence  and  alteration 


4'24  Ovuridn   Cysts. 

of  .sanguineous  effusions  that  Jeep  colors  are  due ;  there  are  also 
sometimes  crystals  of  cholesteriiie ;  in  small  cysts,  rice-like  masses 
are  observed.  In  papillary  cysts,  from  the  absence  of  caliciform 
cells,  the  liquid  never  gains  a  viscosity  comparable  to  that  of  the 
glandular  cysts. 


Fig.  228.^Papillary  tumor  of  the  ovaries  covering 
the  whole  of  the  broad  ligament  (Doran). 

The  chemical  characters  of  the  liquid  have  raised  great  hopes  at 
present  a  little  disappointed ;  by  their  means  it  has  been  believed 
possible  to  make  the  differential  diagnosis  between  ovarian  and 
ascitic  fluids,  in  cases  where  the  external  characters  have  left  doubt. 
A  substance,  paralbumen,  was  considered  by  Waldeyer  as  character- 
istic of  ovarian  cysts.  It  appears  certain  that  it  is  almost  constant, 
at  least  in  glandular  cysts ;  as  to  papillary  cysts,  they  may 
contain  only  traces  of  it.  Out  of  twenty-thi-ee  cysts  examined, 
Oreum  has  found  paralbumen  in  eighteen  eases,  and  has  not  found 
it  in  five.  I  add  that  the  presence  of  this  substance  has  been 
demonstrated  in  the  mucus  of  the  bronchi,  in  a  cyst  of  the  neck,  in 
the  urine  of  patients  suffeiing  from  osseous  suppuration,  and  even 
in  cases  of  ascites.  By  that  we  see  how  much  caution  is  needed  in 
the  use  of  this  means  of  diagnosis.  I  refer  for  the  intlication  of  the 
teclmical  methods  of  the  examination  for  paralbumen  to  the  works 
of  Huppert  and  Hammersten.  Another  fact  furnished  by  chemical 
analysis,  and  which  appears  more  conclusive,  is  dra^\'u  from  the 
proportion  of  sohds  in  the  different  liquids.  According  to  Mehu, 
if  they  approach  seventy  grammes  per  litre,  we  have  surely  to  do 
wth  an  ovarian  cyst.  According  to  Quenu,  this  figiire  would  be  too 
small  and  should  be  raised  to  one  hundred.  The  point  then  is  of 
value. 

III.  Dermoid  cysts. — These  cysts  are  most  frequently  smaU,  but 
they  also  become  quite  volummous  by  combination  with  proliferous 
cysts,  or  even  simply  fi-om  an  inflammatory  impulse  which  suddenly 
increases  the  proportion  of  the  litjuid  contents.     Though  they  may 


Ovarian  Cysts. 


425 


long  remain  uniecognized,  even  until  revealed  bj^  an  autopsy,  as 
soon  as  they  commence  to  enlarge  they  approach,  in  a  clinical  point 
of  view,  the  ordinary  cysts  or  the  proliferous  cysts.  Both  ovaries 
have  been  seen  transformed  into  dermoid  cysts.  Poupinel  has 
collected  forty-four  cases  of  this  kind.  Their  frequence  is  much 
less  than  that  of  the  proliferous  cysts.  Olshausen  has  collected  two 
thousand  two  hundred  and  seventy-five  cases  and  out  of  this  number 
there  were  only  eighty  dermoid  cysts  (3.5  per  100). 


Fig.  230. — Dermoid  cyst  of  the  ovary  (Wyder). 


426  Ovarian  Cysts. 

Their  internal  surface  is  lined  with  a  membrane  which  has  the 
appearance  of  the  skin  and  presents  its  structure.  There  is  seen  a 
corneous  layer  formed  liy  several  rows  of  flat  cells,  then  spherical, 
as  in  the  Malpigian  structures.  An  adipoise  layer  separates  the 
dei-moid  tunic  from  the  fibrous  sac  of  the  cyst.  At  the  surface  of 
the  dermoid  layer  there  exist  papillae,  which,  by  their  reunion, 
have  simulated  a  breast  in  some  cases,  and  hairs,  wliich  are  im- 
planted in  hair  follicles,  sometimes  pro^"ided  with  sebaceous  glands. 
Sudoriparous  glands  are  also  found.  The  hairs,  implanted  or  free, 
are  long,  of  tawny  color,  agglutinated  with  sebaceous  material  and 
rolled  into  balls.  An  agglomeration  of  sebum,  resembling  vernix. 
caseosa,  more  or  less  fills  the  sac  and  often  forms  isolated  balls. 
This  fat,  which  sometimes  has  an  oily  consistency,  contains  a 
large  quantity  of  epithelial  cells,  crystals  of  cholesterine  and  fatty 
acids.  Teeth  and  bones  are  frequently  found  in  these  cysts.  These 
are  implanted  in  the  sac  and  more  or  less  covered  by  the  dermoid 
layer;  they  are  of  irregular  form,  generaUy  flat,  and  are  formed 
of  compact  tissue.  Cartilage  is  present  in  small  masses,  and 
sometimes  the  bones  are  articulated  by  the  interposition  of 
fibrous  fascicuU.  The  teeth  are  enclosed  in  the  wall  and 
project  into  the  cavity.  They  are  implanted  in  bony  debris, 
hohowed  out  like  alveoli,  in  which  they  adliere  slightly.  They  only 
vaguely  present  the  form  of  perfect  teeth  and  never  entirely  respond 
to  the  type  of  incisors,  canines  or  molars ;  the  cementum  is  ordi- 
narily missing.  A  curious  remark  of  Hollaender  is,  that  the  teeth 
are  always  exactly  placed,  a  little  inclined  toward  the  middle  axis 
of  the  body,  so  much  so,  that  by  examining  the  ulterior  of  a  cyst  it 
can  be  determined  to  which  side  it  belongs.  Up  to  one  hundi-ed 
both  have  been  found  (Sehnabel).  Autenrieth  has  described  a  case 
where  tlu-ee  hundred  teeth  were  removed  from  a  cyst  wliich  con- 
tained still  more.  Some  authors  say  they  have  found  carious 
teeth.  But,  as  Lannelongue  says,  w^e  may  believe  with  Magitot, 
that  it  is  a  question,  not  of  true  caries,  but  simply  phenomena  of 
wear  and  reabsorption.  P.  Euge  has  found  in  a  dermoid  cyst, 
below  a  bone  which  resembled  an  inferior  maxillary  pro^"ided  with 
teeth,  a  small  mass,  which,  by  its  form,  its  size  and  its  acinus 
structure,  gave  the  idea  of  a  submaxillary  gland. 

Nonstriated  muscular  fibers  have  been  seen  in  the  inner  layer 
(Virchow) ;  as  to  striated  fibers,  they  have  been  denied  by  01s- 
hausen,  who  believes  that  in  such  cases  not  dermoid  cysts,  but 
tcratomata  are  in  question.  In  truth,  many  authors  confound  these 
two  productions.  Cruveilhier  has  cited  a  case  where  he  had  found 
finger  nails.  Baumgartner  has  reported  a  more  remarkalile  case, 
where  the  cyst,  besides  the  skin,  ban  aud  teeth,  contained  a  body 
resembling  an  eye  with  a  sort  of  convex  cornea  and  an  epithelium 
of  the  nature  of  that  of  the  retina.     There  was  also  in  this  cyst 


Ovarian  Cysts.  427 

some  mucous  membrane  analogous  to  that  of  the  intestine  and 
stomach ;    finally,  nervous  encephaloid  material. 

The  presence  of  gray,  nervous  matter  in  dermoid  cysts  solves 
some  very  great  difficulties.  In  one  case  Virchow  found  a  nervous 
structure  like  that  of  the  brain.  Key  found  a  similar  structure 
in  an  osseous  cavity ;  Eokitansky,  in  a  sort  of  capsule,  near  the 
implantation  of  a  bone.  Other  anatomists  have  found,  exception- 
ally, nervous  filaments  going  to  the  teeth.  Besides  these  solid 
structures,  dermoid  cysts  contain  a  milky  fluid,  often  with  crystals 
of  cholesterine  floating  in  it. 

Mixed  tumors,  formed  by  the  combination  of  dermoid  cysts  with 
other  forms  of  cysts  of  the  ovary,  were  noted  and  described  some- 
time ago.  Eecently  they  have  been  described  anew  by  Poupinel, 
from  whom  I  borrow  the  following : 

"  In  the  same  tumor  there  are  found  together  dermoid  cysts  and 
cysts  with  epithelium  that  may  be  pavement,  cubical,  ciliated, 
caliciform,  polymorphous,  etc.  Still  more,  there  may  be  united  in 
the  same  cystic  cavity  the  epidermis  with  its  appendages  (hair, 
sebaceous  glands,  sudoriferous  glands)  and  a  covering  of  epithe- 
lium that  may  be  uniform  or  polymorphous.  Finally,  the  internal 
covering  of  the  cells  may  be  entirely  composed  of  skin;  but  quite 
frequently  even  in  these  cases  the  cutaneous  lining  is  incomplete. 
In  fact  it  has  been  seen  in  several  cases  that  the  skin  only  existed 
in  one  or  several  points  of  the  dermoid  cavity.  It  often  takes  the 
form  of  a  large  papilla,  which  commonly  serves  only  as  a  point 
of  implantation  of  the  hair.  The  rest  of  the  wall  presents  a 
smooth,  fibrous  aspect,  or  resembles  a  mucous  membrane  more 
than  skin.  A  number  of  so-called  dermoid  cysts  could  be  classed 
without  doubt  among  the  mixed  tumors." 

The  fibrous  framework  is  most  frequently  composed  of  yellow 
connective  tissue.  Besides  the  teeth,  which  are  of  ectodermic 
origin,  and  that  are  found  in  the  vicinity  of  a  cutaneous  linmg, 
there  are  observed,  in  the  fibrous  walls  of  mixed  tumors,  cartila- 
ginous and  osseous  tissue.  These  have  even  been  found  in  tumors 
which  have  no  dermoid  character.  Poupinel  has  reported  an 
example  of  a  mucoid  cyst  of  the  ovary  in  the  walls  of  which  there 
existed  cartilaginous  nodules.  Ossification  is  quite  frequent  in  the 
mixed  tumors,  as  in  the  pure  dermoid  cysts,  but  the  study  of  mixed 
tumors  brings  out  the  interesting  point  that  the  osseous  plaques  are 
not  necessarily  in  the  vicinity  of  the  dermoid  layers,  and  that  in 
some  cases  they  are  entirely  independent.  Finally,  in  the  stroma 
of  mixed  tumors,  still  other  tissues  are  found,  striated  and  non- 
striated  muscular  tissue,  nervous  tissue. 

Both  ovaries  may  be  affected  simultaneously.  Then,  as  in  the 
case  of  unilateral  ovarian  tumors,  all  kinds  of  association  are 
possible  between  the  different  varieties  of  tumor. 


4-28  Ovarian  0/»/«. 

The  question  of  the  genesis  of  dermoid  cysts  is  one  of  the  mo^t 
obscure  problems  of  general  pathok)g>-.  The  theory  which  makes 
them  the  product  of  an  extrauterine  pregnancy,  is  hardly  worth 
mentioning,  since  these  productions  are  so  often  met  in  cliildi'en. 
The  theory  of  diplogenesis  by  fcetal  inclusion  is  also  inadmissible, 
and  the  presence  of  the  excessive  number  of  teeth  is  sufficient  to 
refute  it.  The  term  plastic  heterotopia,  employed  by  Lebert  to 
unite  all  these  facts,  is  not  an  explanation  but  a  designation. 
There  are  a  number  of  other  more  plausible  theories.  That  of 
pai-thogenesis  which  invokes  the  power  of  the  germinal  epithelium, 
is  made  doubtful  by  the  presence  of  analogous  neoplasms  in  otht-r 
parts  of  the  body,  where  this  special  epithelium  does  not  exist. 
The  theory  of  inclusion,  although  still  open  to  criticism,  is 
altogether  the  most  satisfactory.  It  assumes  that,  during  intra- 
uterine life,  certain  parts  of  the  blastoderm  have  been  included  in 
the  midst  of  the  tissues,  and  that  they  finally  develop  by  giving 
rise  to  a  anomalous  formation  of  those  tissues  uoi-mally  derived 
from  them. 

r\'.  Parovarian  Cysts. — In  a  practical  point  of  view,  it  is 
impossible  to  radically  separate  cysts  of  the  ovarian  region  inde- 
pendent of  the  ovary  from  ovarian  cysts  properly  so-caUed. 
Thus,  although  the  cysts  of  which  I  now  speak  ai-e  not  in  reality 
cysts  of  the  ovary,  since  they  are  anatomically  distinct,  it  is  con- 
venient to  describe  them  at  the  same  time,  holding  to  the  close 
clinical  and  surgical  relations  between  the  two  varieties.  An 
assemblage  of  characters  is  united  in  this  variety  of  cysts  to  make 
them  a  very  detinite  group.  They  are  usually  designated  as  par- 
ovarian cysts,  or  cysts  of  Eosenmuller's  organ,  because  their  evident 
origin  in  the  broad  Kgameut  in  which  they  are  included  coiTesponds 
exactly  to  the  seat  of  these  embryonal  remnants,  and  because  to 
their  special  structure  it  has  appeared  natural  to  assign  a  special 
origin.  However,  it  is  not  proven  that  the  unilocular  cysts  of  the 
"broad  ligaments  of  thin  walls  and  transparent  liquid  contents, 
always  have  theii*  origin  in  the  parovarium.  A.  Dorau  ha.^ 
observed  some  specimens  that  are  inconsistent  with  this  theory. 
He  is  inclined  to  consider  them  as  simple  lacmiar  cysts,  or  the  sub- 
sei'ous  hygromata  of  Verueuil.  Magni  also  believes  that  they 
may  simply  develop  in  the  connective  tissue,  independent  of  the 
parovarium.  De  Sinety  considers  the  origin  in  the  organ  of 
JRosenmuller  as  very  doubtful.  He  associates  them  with  the  mucoid 
epitheliomas  and  believes  that  the  tlifferenee  in  the  Uquid  is  due 
solely  to  the  simplicity  of  the  epithelium,  for  clear  liquid  is  also 
seen  in  the  ovarian  proliferous  cysts  not  lined  with  caliciform  cells. 
De  Sinety  even  asks  if  supernumerary  ovaries  may  not  play  a  part 
in  the  production  of  these  cysts.  But  if  they  have  the  same  origin 
as  cysts  of  the  ovary,  how  shall  we  explain  the  constant  peculiaritj' 


Ovarian  Ci/sfs. 


429 


of  their  structure  ?  How  can  we  believe  in  such  a  frequence  of 
supernumerary  ovaries  ?  However,  it  is  convenient  to  adopt  the 
expression  consecrated  by  use  to  designate  cysts  in  the  region  of 
the  ovary,  independent  of  that  organ;  but  the  term  parovarian 
cyst  should  be  extended  to  mean  a  cyst  contiguous  with  the  ovary 
rather  than  a  cyst  of  the  parovarium.     These  growths  are  not  rare. 


Fig.  231. — Unilocular  parovarian  cyst  of  the  broad  ligament  (Doran). 


Fig.  232. — Cystic  disease  of  the  ovaries  (Barnes). 

Olshausen  has  met  them  thirty-two  times  out  of  two  hundred  and 
eighty-four  ovariotomies,  or  11.3  per  hundred.  It  is  important  to 
distinguish  two  varieties  of  these  cysts.  One,  the  most  frequent, 
I  shall  call  hyaline  parovarian  cyst,  the  other,  more  rare,  papillary 
parovarian  cyst. 


430  OvUrian  Cysts. 

Hyaline  parovarian  cysts. — Cysts  of  this  variety  are  ordinarily  uni- 
locular. There  are  some  exceptions.  Lawson  Tait  has  removed  one 
with  six  divisions  and,  according  to  him,  Spencer  Wells  has  operated 
on  a  bilocular  cyst.  Even  when  they  seem  unilocular,  small  secondary 
ca\aties  are  often  found  if  the  walls  of  the  cyst  are  searched  with 
care.  The  sac  is  remarkably  thin.  Its  external  surface  is  covered, 
but  without  adhesion,  by  the  folds  of  the  broad  ligament  at  all 
points  where  it  is  not  in  immediate  contact  with  the  walls  of  the 
pelvis  or  the  contiguous  organs.  However,  in  some  cases  an 
elongation  of  the  broad  ligament  furnishes  a  large  pedicle.  When 
the  cyst  is  sessile,  it  is  united  quite  loosly  to  the  contiguous  parts, 
unless  there  has  been  a  previous  inflammation.  Its  color  is  a 
slightly  greenish  white,  and  the  fine  vessels  of  the  peritonaeal 
covering  are  clearly  shown  by  its  transparency.  The  tube  Hes 
against  the  surface  of  the  ovary ;  the  first  effect  of  its  development 
having  been  to  double  up  the  tubal  wing.  The  ovary  is  pushed  to 
the  external  side,  sometimes  flattened,  but  always  very  distinct. 
The  internal  surface  is  smooth  and  covered  with  ciliated  epithe- 
lium, which  can  be  compared  to  the  ordinary  cylindi-ical  epithe- 
lium. The  liquid  is  very  clear,  comparable  to  spring  water.  Its 
density  is  somewhat  greater  than  that  of  water  (1002  to  1008).  It 
is  not  precipita.ted  by  heat,  for  it  contains  no  albumen  when  there 
has  been  no  suppuration  or  sanguineous  effusion.  A  considerable 
proportion  of  chloride  of  sodium  has  been  noted. 

Papillary  parovarian  cysts. — Is  this  variety  ordinarily  distinct, 
or  is  it,  as  Lawson  Tait  believes,  only  a  phase  of  the  preceding? 
It  is  impossible  to  say.  However,  it  is  important  to  note  the 
existence  of  this  variety.  Certain  authors  use  as  synonymous 
terms  the  words  parovarian  cyst  and  cyst  of  the  broad  ligament,  and 
believe  besides  that  these  parovarian  cysts  are  always  of  the  variety 
having  thin  walls  and  transparent  contents,  poor  in  albuminoid 
si;bstances.  Now  this  variety  is  certainly  the  most  numerous,  but 
not  the  only  one.  There  are  some  parovarian  cysts  wliich  have  a 
viscid  contents.  For  this,  it  is  sufficient  that  their  walls  present 
papillary  vegetations.  The  contents  may  even  be  made  albuminous 
and  diversely  colored  by  sanguineous  extravasations.  But  these 
characters  give  rise  to  no  confusion  with  the  mucoid  cyst  of  the 
ovary,  that  are  exceptionally  included  in  the  broad  ligament.  A 
particular  distinction  always  consists  in  the  fact  that  they  are 
Tinilocular  (making  abstraction  of  the  microscopic  cavities  of  their 
Avails),  while  cysts  of  the  ovary  are  almost  invariably  multilocular. 
Exceptionally,  these  cysts,  by  developing  especially  on  the  abdom- 
inal side,  take  a  certain  mobility,  and  draw  out  the  broad  ligament 
in  such  a  way  that  it  constitutes  a  laminated  tissue.  These  cysts, 
ordinarily  so  benign,  may  also  acquire  an  extreme  malignity. 


Ovarian  Cysts.  431 

Parovarian  dermoid  cysts. — Quite  a  number  of  authentic  cases 
of  dermoid  cyst  have  been  observed  in  the  broad  ligament,  inde- 
pendent of  the  ovary. 

Cysts  of  medium  development. — Small  residual  cysts  {Wolffian  and 
Mullerian). — There  are  frequently  found,  especially  in  cases  of 
uterine  fibroids,  or  commencing  tumor  of  the  ovary,  either  in  the 
broad  ligament,  or  about  the  tube,  some  small  transparent  vesicles 
that  have  no  surgical  interest,  but  of  an  anatomical  significanee 
that  deserves  notice.  This  cyst  presents  thi-ee  varieties  :  1.  Cyst 
of  Morgagni's  hydatid  (Fig.  232)  appended  to  the  pavilion  of  the 
tube,  varies  in  volume  from  that  of  a  pea  to  that  of  a  cherry,  is 
transparent  and  lined  with  a  single  layer  of  epithelium.  It  is 
known  that  this  hydatid  is  the  remnant  of  the  extremity  of  Muller's 
tube.  2.  Supratubal  cysts  scarcely  exceed  the  preceding  in  size, 
presenting  the  same  appearance  and  the  same  structure.  It  seems 
to  be  a  micro-cyst  of  the  broad  ligament  that  has  pushed  under  the 
peritonaeum  to  occupy  this  unusual  situation.  3.  Micro-cysts  of 
the  broad  ligament  are  those  which  are  dependent  on  the  organ  of 
EosenmuUer,  and  others,  which  are  independent  and  whose  exact 
origin  is  undetermined.  According  to  Doran  only  those  which 
arise  in  the  vertical  tubes  of  the  parovarium  contain  cihated 
epithelium  and  become  papillary  by  their  ultimate  development ; 
the  other  cysts,  those  wliich  arise  outside  the  parovarium,  and  even 
those  of  the  horizontal  tube  are  lined  with  a  simple  endothelium. 
It  is  impossible,  at  present,  to  affirm  that  the  micro-cysts  of 
this  third  variety  have  as  clearly  limited  an  evolution  as  those  of 
the  first.  It  even  appears  probable  that,  if  some  remain  insignifi- 
cant during  all  their  evolution,  others,  under  the  influence  of  an 
unknown  u-ritative  influence  may  be  the  point  of  departure  of 
large  cysts  of  the  broad  ligament  of  purely  liquid  contents  of 
papillary  structure. 

II.  Follicular  cysts. — Dropsy  of  the  Graafian  follicle  has  long 
been  considered  as  the  sole  or  the  principal  cause  of  the  develop- 
ment of  the  large  cysts  of  the  ovary.  Some  English  authors  still 
believe  in  this  theory,  but  it  should  be  completely  abandoned. 
Cysts  which  belong  to  this  origin  are  always  of  medium  size,  and 
if  they  cause  morbid  symptoms  it  is  rather  from  chronic  inflam- 
mation of  the  appendages  than  in  imitation  of  an  ovarian  cyst. 
Eokitansky  has  put  the  fact  of  dilatation  of  the  Graafian  foUiele 
beyond  doubt,  and  other  authors  have  given  this  anatomical  form 
the  term  under  which  it  has  been  described.  Follicular  dropsy 
forms  a  smaU  unilocular  sac  from  the  size  of  a  hemp-seed  to  that 
of  a  nut.  But  the  agglomeration  of  several  of  these  sacs  may, 
exceptionally,  give  the  ovary  the  size  of  the  fist  or  of  a  foetal  head. 
The  wall   is  smooth,  lined  with  a  single  epithelial  layer.     Often 


432 


Ornrioii   Ci/Hfu. 


ail  ovule  may  be  discovered  eveu  in  quite  a  large  cavity.  In  the 
new-bom  extremely  developed  follicles  are  often  found  toward  the 
centre  of  the  ovary.  They  appear  to  depend  on  an  impulse  of 
evolution  occurring  about  the  time  of  birth.  But  it  would  be  aa 
abuse  of  language  to  give  these  large  follicles  the  name  of  cysts. 


Fig.  233. — Cystic  disease  of  the  ovaries.     /.  tube  ; 
17  i,  myxomatous  follicular  cysts. 


Fig.  234. — Cystic  disease  of  the  ovary  (section  of  the  preceding  illustration  of  natural 
size),  a  a,  small  myxomatous  cysts ;  b  b,  large  myxomatous  cysts ;  e  e,  follicular  cysts, 
with  liquid  contents;  egg,  ioUicular  cysts,  with  caseous  contents-  of  f,  ovarian  tissue 
containing  small  follicular  cysts. 

The  large  conglomerate  follit-ular  cysts  which  transform  the  ovary 
into  a  multiloc-ular  mass,  constitute  a  definite  anatomical  type 
which  corresponds  to  a  special  chnical  type.     I  believe  it  would 


Ovarian  Cysts. 


433 


be  of  interest  to  distinguish  this  lesion  from  other  cysts  of  medium 
development  by  the  term  cystic  disease  of  the  ovary.  These  con- 
glomerate cysts,  which  as  a  whole  rarely  exceed  the  size  of  the 
head,  are  not  the  first  stage  of  a  more  voluminous  tumor,  as 
formerly  believed.  They  preserve  their  medium  proportions 
indefinitely,  and  are  thus  separated  from  proliferous  glandular  cysts 
in  a  surgical  point  of  view  as  well  as  in  an  histological. 


Fig.  235. — Follicular  cyst  of  the  ovary,  with  myxomatous  degeneration  (fifty  di- 
ameters). A  A,  loose  myxomatous  tissue  toward  the  interior  of  the  cyst;  B  B, 
myxomatous  tissue,  dense  toward  the  external  surface. 

The  micro-cystic  alterations  wliicli  accompany  ovarian  sclerosis, 
although  having  an  analogous  histological  origin,  the  follicle,  form 
also  an  anatomical  and  clinical  type  perfectly  independent.  The 
cavities  always  remain  so  small  that  they  do  not  sensibly  deform 
the  ovary,  and  are  never  transformed  into  a  tumor.  In  this  lesion, 
which  really  belongs  to  ovaritis,  Avith  wliieh  I  have  already  described 
it,  the  ovary  appears  strew^l  with  cysts  as  large  as  a  hemp-seed. 
They  have  been  wrongly  considered  by  some  authors  as  physio- 
logical phenomena  of  evolution.  In  reality  this  is  a  pathological 
process  which  occurs  alone  or  in  connection  with  a  contiguous 
irritation,  as  a  uterine  fibroma  or  an  inflammation  of  the  tube. 
The  sclerous  modification  of  the  ovarian  stroma  is  only  secondary 
but  it  is  an  habitual  consequence  of  follicular  degeneration.  The 
contents  of  these  cavities,  in  cystic  disease  of  the  ovary,  is  serous 


434  '  Ovarian  Cijsts. 

or  sanguinolent.  However,  I  liuve  extirpated  a  polycystic  ovary 
in  which  some  of  the  sacs,  varying  from  the  size  of  the  head  of  a 
pin  to  that  of  a  nut,  were  tilled  with  a  serous  liquid,  while  others 
contained  a  caseous  or  lardaceous  material,  in  which  myxomatous 
tissue  was  recognized  on  microscopic  examination.  The  lesion 
was  unilateral;  the  other  ovary  being  sclero-cystic.  This  is  a 
variety  of  secondary  degeneration  of  follicular  cysts  which  has  not 
been  previously  described  CFigs.  233,  234,  235). 


Fig.  236, — Cyst  of  the  corpus  luteum,  natural  size  (Nagel). 


III.  Cysts  of  the  corpus  luteum. — To  Eokitansky  we  owe  the 
first  description  of  this  variety  of  cyst.  He  beUeved  that  only  the 
corpus  luteum  of  pregnancy  could  be  transformed  into  cysts,  but 
Gottschalk  has  found  it  in  a  nulliparous  woman.  The  cysts  do  not 
usually  pass  the  size  of  a  nut.  Some  have  been  cited,  however, 
which  much  exceeded  these  proportions.  The  two  tumors  described 
by  Gottschalk  were,  one  the  size  of  an  orange,  the  other  that  of  a 
small  apple.  Schroeder  has  seen  one  the  size  of  a  pigeon's  egg. 
Nagel  has  observed  them  the  size  of  an  apple,  and  even  of  an 
adiUt  head.  Microscopical  examination  of  the  wall  shows  papillary 
gi'anulations  characteristic  of  the  corpus  luteum  and  can  leave  no 
doubts.  It  will  prevent  confounding  cysts  of  the  corpus  luteum 
with  follicular  cysts  whose  walls  are  thick  and  closed  by  bloody 
deposits,  or  even  w4th  a  suppurating  ovaritis  with  inspissation  of 
pus,  when  these  cj^sts  are  inflamed  under  the  influenceof  a  con- 
comitant salpingitis. 

To  understand  the  development  of  the  cysts  at  the  expense  of 
what  is  generally  considered  as  a  cicatricial  process,  it  is  necessary 
to  remark  that  the  idea  of  the  retraction  of  the  tissues  for  the 
formation  of  the  corpus  luteum  is  altogether  erroneous ;  it  should 
be  replaced  by  the  idea  of  proliferation  and  neoformation  of  ovarian 
tissue  (Call  and  Exner).  The  new  theories  proposed  by  Toupet 
will  even  put  the  formation  of  the  corpus  luteum  into  the  general 
law  of  development  of  tissues,  by  attributing  to  it  a  process 
identical  ^^^th  that  observed  in  the  mucous  membranes  in  progress 
of  development  or  at  the  time  of  their  inflammation. 

Tuho-ovarian  cysts. — I  shall  place  here  some  details  relative  to  a 
variety  of  cysts  which  are  worthy  of  mention  and  classification  in 


Ovarian  Cysts'.  435 

consequence  of  an  important  morphological  peculiarity  which  they 
owe  to  their  acquired  connections  with  the  tube.  The  ovarian  cyst 
is,  in  these  cases,  engrafted  upon  the  dilated  tube  which  commu- 
nicates with  it,  so  that  the  cavity,  generally  bent  in  the  form  of  a 
horn,  consists  of  a  tubular  portion  and  an  ovarian  portion. 
Eichard  first  gave  a  good  description  of  this  anatomical  variety. 


Fig.  237.  —  Cyst  of  the  corpus  luteum  (sixty  diameters)  (Nagel).  a,  connective 
tissue  deprived  of  epithelium  on  its  internal  surface ;  b,  yellow  layer  of  the  corpus 
luteum ;  c,  normal  tissue  of  the  ovary. 

Generally  these  are  the  small  ovarian  cj'sts  (cysts  of  the  Graafian 
follicle)  which  are  thus  joined  to  the  dilated  tube,  so  that  their  size 
is  not  usually  larger.  But  Hildeljrand  and  Olshausen  have  seen 
tubo-ovarian  cysts  formed  by  proliferous  cysts,  having,  in  conse- 
quence, very  large  dimensions,  and  tw^o  other  cases  of  this  last 
author  were  truly  cysts  of  the  broad  ligament.  This  variety  may 
then  be  superadded,  so  to  speak,  to  all  kinds  of  cysts.  The  tube 
generally  remains  permeable,  which  permits  the  liquid  to  flow  into 
the  uterus  when  the  pressure  in  the  sac  becomes  exaggerated. 
Thus  we  have  a  profluent  ovarian  dropsy,  which  may  be  compared 
to  what  has  been  described  in  hydrosalpinx  under  the  name  of 
profluent  tubular  drops^.  This  communication  acts  as  a  safety  ' 
yalve  which  prevents  the  extreme  distention  of  the  cyst  and 
opposes  its  growth.  Hennig  has  been  able  to  prove,  in  one  case, 
the  periodic  diminution  of  bilateral  tumors  after  their  evacuation. 
As  to  the  genesis  of  these  composite  cysts,  it  may  be  asked  whether 
the  adhesion  of  the  tube  to  the  ovary  preceded  or  followed  the 
formation  of  the  cyst,  if  there  has  not  first  been  inflammation  of 
the  appendages  causing  their  adhesion,  or  previous  coincidence  of 
hydrosalpinx  and  ovarian  cyst  united  and  fused  by  absorption 
of  the  septum.     I  am  indiaced  to  believe,  for  my  part,  that  such  is 


436 


Ovarian  Cysts. 


most  frequently  the  case;  so  that  the  lesion  may  be  as  well 
described  in  the  chapter  on  the  pathologj'  of  the  tube  as  that  of 
the  diseases  of  the  ovary.  Out  of  three  hundred  ovariotomies, 
Olshausen  has  found  three  cases  of  tubo-ovarian  cysts,  of  which 
one  was  bilateral. 

Pedicle. — Whatever  may  be  the  origin  of  ovarian  cysts,  an 
important  morphological  peculiarity  dominates,  one  may  say,  their 
surgical  history.  It  is  the  presence,  the  diverse  dispositions,  or  the 
absence  of  a  pedicle  fastening  them  to  neighboring  tissues.  It  is 
sometimes  very  thin,  almost  membraneous,  and  the  tube  is  sepa- 
rated by  the  free  wing  of  the  ovary  (Fig.  238).  Frequently  this 
wing  has  been  divided  into  two,  and  the  tube,  di-awn  along  the 
tumor,  adheres  to  it  and  undergoes  a  certain  amount  of  elongation 
as  the  tumor  grows.  The  pedicle  then  contains  two  parallel  cords, 
the  tube  and  the  ovarian  ligament.  The  narrowest  part  of  the 
jjediele  is  usually  at  the  level  of  what  is  called  the  infundibulo- 
pelvic  ligament,  when  a  fold  of  peritonaeuu  extends  from  the  pehic 
wall  to  the  ovary  by  which  the  vessels  approach  the  organ. 


Fig.  23S. — Pedicle  of  a  cyst  of  the  ovarj-. 

The  length  and  thickness  of  the  pedicle  are  extremely  variable. 
This  depends  on  the  chstance  which  separates  the  tumor  from  the 
l)order  of  the  uterus  and  the  thickness  of  the  large  ligament  whose 
muscular  fibers  are  sometimes  hypertrophied,  the  connective  tissue 
aidematous,  and  the  veins  dilated.  Finally,  it  is  at  the  edge  of  the 
pedicle  that  the  cyst  walls  sometimes  present  then-  greatest  thick- 
ness and  that  vestiges  of  the  ovary  may  be  found.  The  pedicle 
which  some  cysts  included  in  the  broad  ligament  (dermoid  and 
parovarian)  may  exceptionally  present,  is  formed  by  the  simple 
distention  and  displacement  of  the  peritonaeum,  is  large,  laminated 
and  membraneous. 

^Yhen  the  pedicle  is  wanting,  the  cyst  is  included  in  the  broad 
ligament,  totally  or  in  part.  This  is  the  habitual  situation  of 
hyaline,  papillary  and  parovarian  cysts,  of  some  dermoid  cysts, 
and  finaUy  of  some  proliferous  ovarian  cysts,  glandular  or  papil- 
lary,, for  the  explanation  of  which  Freund  invokes  a  congenital 
malformation  consisting  in  the  excessive  inclusion  of  the  ovary. 
Small  folUcular  cysts  and  cysts  of  the  corpus  luteum  may  excep- 
tionally have  this  situation,  as  I  have  obsen-ed  (Fig.  289).     The 


Ovarian  Cysts. 


437 


class  of  cysts  included  in  the  broad  ligament  is  thus  essentially 
artificial ;  it  possesses  a  great  interest  from  the  surgical  point  of 
view,  but  this  peculiarity  cannot  serve  as  a  basis  for  a  nosological 
classification.  It  is  wrong  to  make  this  term  synonymous  with  that 
of  parovarian  cysts,  which  are  more  frequent  and  have  a  thin  sac 
with  hyaline  liquid  contents.  In  fact,  the  following  varieties  of 
cysts  may  be  included  in  the  broad  ligament:  1.  Cysts  of  large 
development :  (a)  parovarian  cysts,  hyaline  and  papillary ;  (b) 
proliferous  cysts  of  the  ovary,  papillary  and  glandular  (rarely) 
(c)  dermoid  cysts,  ovarian  or  parovarian.  2.  Cysts  of  medium 
development ;  (a)  follicular  cysts ;  (b)  cysts  of  the  corpus  luteum 
(c)  Kesidual  cysts.  The  included  cysts  may,  according  to  the  case 
occupy  only  the  external  side  of  the  ligament,  toward  the  pelvis 
or  its  internal  portion,  and  lie  against  the  uterus,  or,  finally 
occupy  the  whole  of  the  broad  ligament  and  displace  that  organ 
toward  the  opposite  side.  An  important  portion  of  the  cyst  may 
lift  the  broad  ligament  toward  the  abdominal  cavity,  by  forming  a 
free  superadded  cyst  separated  from  the  included  portion  by  a 
sulcus. 


Fig.  239. — Conglomerate  follicular  cysts  included  in  the  broad  ligament. 

According  to  Terrillon,  the  secondary  inclusion  of  the  proliferous 
cysts  differs  from  the  primary  inclusion  of  the  pa,rovarian  cysts. 
In  the  first  case  the  included  portion  of  the  cyst  contracts  such 
intimate  adhesion  with  the  contiguous  portions  that  they  add  to 
the  primary  vascular  utero-ovarian  pedicle  a  secondary  vascular 
pedicle.  Such  a  distinction  is  quite  illusory  and  based  on  obser- 
vations restricted  to  the  hyaline  variety  of  parovarian  cysts. 
Some  papillary  parovarian  cysts  have  a  remarkable  tendency  to 
invade  the  contiguous  parts  and  especially  to  adhere  to  the  uterus. 

It  is  important  to  distinguish  a  special  variety  of  sessile  cysts. 
These  do  not  remain  included  in  the  broad  ligament  but  exceed  its 
limits  by  burrowing  under  the  peritonaeum  into  the  cellular 
interstices  far  from  theii-  point  of  origin.  They  have  been  called 
retro-peritonseal  cysts.     Any  variety  of  cyst  may  take  this  course. 


438 


Ovarian  Cysts. 


It  has  been  especially  observed  in  the  hyaline  and  papillary  par- 
ovarium cysts,  Imt  also  has  been  noted  in  dermoid  cysts,  and  in 
the  glandular  ovarian  cysts.  To  the  left,  the  tumor  may  push  up 
the  iliac  meso-eolou  and  come  in  contact  with  the  ilium.  To  the 
right,  the  cyst  may  advance  to  the  caecum.  It  may  also  advance  in 
the  mesentery  to  the  kidney,  the  liver  and  even  to  the  diaphi-agm. 
Posteriorly,  Douglas'  cul-de-sac  is  pushed  up  by  cystic  accumu- 
lation between  the  rectum  and  uterus.  Forward,  the  vesico-uterine 
cul-de-sac   is   sometimes   uplifted   and  the  bladder  is   elongated. 


Fig.  240.  —  Retro-peritonseal  dermoid  cyst  (Sanger).  K,  cyst;  U,  uterus;  R, 
rectum;  V,  vagina;  P,  peritonaeum;  Ead  and  E  a  g,  levator  ani ;  I  r,  ischio-rectal 
fossa;   Ur,  urethra. 

Laterally,  the  cystic  mass  burrows  under  the  peritonaeum  between 
it  and  the  pelvic  aponeuroses,  and  even  into  the  iliac  fossae, 
compressing  the  ureters  and  frequently  causing  alterations  of 
the  kidneys.  These  are  papillary  cysts  and  glandular  cysts  of  the 
areolar  and  gelatinous  variety,  which  give  rise  to  retro-peritongeal 
migrations  much  more  extensive  and  more  serious  than  those  of 
hyaline  parovarian  cysts.     These  tumors  are  strongly  adherent  to 


Ovarian  Cysts. 


43y 


the  contiguous  parts,  and  it  is  very  difficult  and  sometimes  impos- 
sible to  enucleate  them.  Dermoid  cysts  have  also  been  seen  to 
lodge  in  the  retro-peritonseal  pelvic  cellular  tissue. 


Fig.  241.  — Cyst  of  the  ovary  complicating  pregnancy.     O  T,  cyst  pushed  out  of  the 
pelvis  by  the  uterus :   F  H,  center  of  asculatation  of  the  foetal  heart  sounds. 

Adhesions. — In  the  first  stages  of  the  development  of  cysts  the 
cylindrical  epithelium  which  covers  them  protects  against  the 
formation  of  adhesions  (Waldeyer).  But  the  desquamation  of 
this  covering  permits,  finally,  the  formation  of  adhesions  under 
the  influence  of  friction  and  external  irritations.  Loose  and 
glutinous  in  the  beginning,  they  become  more  and  more  fixed  with 
time.  The  anterior  surface  of  the  cyst  has  been  seen  to  be  so 
intimately  adherent  to  the  peritonaeum  that  operators  have  detached 
this  structure  from  the  abdominal  walls  for  some  distance  under 
the  belief  that  they  were  separating  the  cyst  itself.  The  epiploic 
adhesions  may  be  so  extensive  and  so  vascular  that  the  cyst  finds 
its  principal  source  of  nourislmient  in  them.  The  intestine  may 
be  fused  with  the  cyst  wall  so  that  a  dissection  may  be  impossible. 
Adhesions  to  the  pelvic  walls  are  especially  grave  on  account  of 
the  danger  of  rupture  of  a  ureter  or  of  a  large  vessel ;  it  is  some- 
times impossible  to  overcome  them  when  they  are  very  extensive. 
They  are  almost  always  distinct  adhesions  of  a  retro-peritonaeal 
cyst  without  interposition  of  the  serosa. 

Ascites. — The  presence  of  a  very  small  quantity  of  liquid  in  the 
peritonaeum  is  quite  frequent,  but  its  accumulation  in  the  form  of 


440  Ovarian  Cysts. 

ascitic  effusion  is  rarely  met  with.  The  great  majority  of  cases  of 
ascitic  effusion  occur  in  common  with  papillary  cysts  with  the  issue 
of  vegetations  outside  the  sac,  sometimes  with  abundant  metastasis 
in  the  contiguous  peritouieum.  In  cases  of  glandular  cysts  there 
may  he  a  partial  fatty  degeneration  of  the  sac,  or,  according  to 
Quenn,  rupture  of  very  smaU  superficial  cysts,  producing  irritation 
of  the  peritoneum  liy  their  contents.  Tliis  author  attributes  an 
exaggerated  role  to  the  osmosis  induced  by  the  colloid  material 
secreted  by  the  vegetations  or  exuded  by  the  small  cysts.  It  is 
not  necessary  to  speak  of  ascitic  effusion  caused  by  the  irritation 
of  a  pathological  liquid.  Ascites  constitutes  a  true  mode  of  defense 
on  the  part  of  the  peritonsum,  when  the  serosa  has  not  been  able 
to  isolate  the  irritating  l)ody  by  the  production  of  adhesions.  The 
vascularity  of  the  tumor  has  been  invoked  as  an  explanation  of  the 
production  of  ascites,  but  telangiectasic  fibroids  may  exist  without 
ascites. 

The  character  of  the  ascitic  Hquid  which  accompanies  ovarian 
cysts  often  permits  recognition.  It  is  richer  in  solid  elements  than 
the  ascites  of  cirrhosis  (sixty  to  seventy  gi'ammes  in  the  place  of 
twenty-five  gi-ammes,  according  to  Mehu),  and  often  contains 
characteristic  cellular  elements  (Quenn).  It  may  be  of  a  lemon- 
yellow  color,  or  be  tinged  with  blood.  The  latter  color  'appears  to 
correspond  to  a  greater  malignity  of  the  tumor. 

lutra-ci/stic  Ajjople.rij. — Small  haemorrhages  into  the  interior  of 
the  sac  are  frequent,  giving  the  liquid  its  dark  appearance.  Grave 
hiemorrhages,  thi'eateuing  life,  have  been  observed.  The  cyst  is 
then  distended  by  clots ;  elongation  and  torsion  of  the  pedicle  pre- 
dispose to  hiemorrhages. 

Intiammatiou. — Suppuration  of  a  cystic  cavity  after  exploratory 
puncture  has  been  observed.  The  inti'oduction  of  pathogenetic 
germs  by  this  means  is  beyond  dispute.  It  is  also  to  this  cause 
that  the  so-called  spontaneous  inflammations  should  be  attributed ; 
adhesions  ^rith  inflamed  tubes  have  permitted  the  access  of  germs. 
Suppurative  inflammation  may  succeed  to  torsion  of  the  pedicle. 
Finally,  after  parturition,  the  suppm-ation  of  dermoid  cysts  has 
been  noted  under  the  influence  of  a  puerperal  septicemia. 

Torsion  of  the  pedicU. — This  accident,  though  not  fi'equent,  is 
far  from  being  rare.  The  cyst  may  be  seen  completely  detached 
from  its  primitive  insertion  and  free  in  the  abdomen,  or  only  held 
by  some  fibrous  filaments.  These  incidents  generally  occui"  in 
polycystic  areolar  tumors  or  to  dennoid  cysts  with  thick  walls.  If 
the  tumor  has  not  contracted  adhesions  before  its  separation,  it 
constitutes  a  foreign  body,  which  induces  a  shai"p  reaction  in  the 
peritonieum  and  an  ascites  that  might  be  called  acute.  In  other 
cases,  it  may  continue  to  live  by  its  adventitious  roots.  But  these, 
in  their  turn,  may  siiffer  the  same  accident.     If  the  torsion  is  made 


Ovarian  Cysts.  441 

slowly,  favorable  effects  as  to  the  arrest  of  development  of  the 
neoplasm  may  be  observea.  It  produces  then  a  fatty  degeneration 
with  a  partial  resorption ;  calcification  has  also  been  noted.  But, 
more  frequently,  torsion  is  accompanied  by  the  acute  symptoms 
of  peritonitis  and  increase  in  the  size  of  the  tumor  by  hsemor- 
rhages.  One  of  the  rare  results  of  torsion  is  gangrenous  inflam- 
mation of  the  tumor.     Intestinal  occlusion  may  be  a  consequence. 

Peritoncsal  generalization ;  Metastasis. — The  following  distinctions 
may  be  established :  (a)  Metastasis  by  spontaneous  infection ; 
(b)  Metastasis  by  operative  infection. 

(a)  Metastasis  by  .spontaneous  infection. — The  villous  productions 
of  papillary  cysts  may  long  remain  included  in  the  sac,  but  at 
a  certain  step  vegetations  appear  externally,  either  from  rupture 
from  distention  or  from  erosion  and  perforation  of  a  limited  part 
of  the  wall.  From  this  begins  a  new  departure.  The  peritonaeum 
is  u-ritated  and  ascites  is  produced.  The  neoplasm  also  tends  to 
infect  the  contiguous  parts.  The  vegetations  are  then  found 
disseminated  in  considerable  quantity,  not  only  on  the  ovary,  the 
tube  and  the  uterus,  but  also  on  the  intestines,  the  great  omentum, 
the  parietal  peritonaeum  and  the  aortic  walls.  It  may  be  asked  if 
there  is  not  in  such  a  case  danger  of  the  operation  being  incom- 
plete, and,  what  becomes  of  the  secondary  vegetations  when  the 
principal  tumors  have  been  extirpated '?  Numerous  observations 
show  that,  even  then,  recovery  may  be  permanent,  as  if  the  dissemi- 
nated vegetations  had  undergone  a  secondary  regression.  Meta- 
static infection  of  the  peritonaeum  has  rarely  been  observed  in 
glandular  cysts  of  the  ovary.  They  appear  to  be  consecutive  to 
spontaneous  rupture  of  the  cyst.  In  dermoid  cysts  metastasis  has 
also  been  noted.  Cases  have  been  noted  in  which  the  infection  was 
not  confined  to  the  peritonaeum,  but  invaded  the  pleurs  thi'ough 
the  lymphatics,  after  having  attacked  the  inferior  surface  of  the 
diaphragm.  These  metastases  may  assume  a  malignant  histo- 
logical structure.  Thus  a  dermoid  cyst  may  become  the  point  of 
departure  of  an  epithelioma  susceptible  of  extension  to  the  uterus, 
to  the  omentum,  to  the  duodenum,  to  the  liver,  to  the  spleen,  or  to 
the  lungs.  Degeneration  of  dermoid  cysts  into  mahgnant  neo- 
plasms, epithehoma,  sarcoma,  carcinoma   has  often  been  observed. 

(b).  Metastasis  by  operative  infection. — A  number  of  eases  have 
been  reported  in  which,  shortly  after  ovariotomy,  gelatinous  masses 
{myxoma  peritonei)  have  been  seen  to  appear  in  peritonffium,  seeming 
to  proceed  fi'om  infection  by  similar  material  contained  in  the  cyst. 
These  masses  form  vitreous  nodules,  from  the  size  of  a  hemp-seed 
to  that  of  a  nut,  disseminated,  or  reunited  in  a  mass  wluch  may 
equal  a  uterus  at  term.  They  have  the  coloi"  of  barley  sugar  or 
are  greyish,  and  have  delicate  contractive  tissue  septa,  which  may 
or  may  not  contain  vessels.     Werth  has  shown  that  they  are  not 


442  Ovarian  Cysts. 

tme  myxomata  and  proposes  to  call  them  pseudo  inyxomata  of  the 
peritonfeiim.  Is  the  peritoufeum  destined  to  an  inevitable  infection 
hy  the  effusion  of  the  contents  of  dermoid  cysts  ?  Two  obsei-vatious 
by  Engstrom  show  that  reeovery  may  obtain,  even  though  the 
abdominal  ca\ity  be  veiy  much  contaminated.  It  is  also  known 
that  an  extensive  contamination  of  the  serosa  by  the  colloid  contents 
of  pi'ohferous  cysts,  although  a  bad  c(mdition  for  the  success  of  the 
operative,  does  not  render  it  impossible. 


CHAPTER  XXXI, 


-ffiTIOLOGY,  SYMPTOMS,    PROGRESS   AND 
DIAGNOSIS   OF   OVARIAN   CYSTS. 

Etiology. — It  is  during  the  period  of  sexual  activity  that  cysts  of 
the  ovary  are  especially  observed.  However,  it  is  certain  not  only 
that  the  germ  of  many  of  these  tumors  exists  in  the  fcetal  period, 
but  also  that  the  neoplasm  has  sometimes  begun  during  this  state 
and  remained  latent  to  the  impulse  which  permits  its  development. 
This  cannot  be  doubted  for  dermoid  tumors,  and  numerous  obser- 
vations tend  to  show  that  the  same  is  true  for  the  proliferous  cysts 
(mucoid  cysts,  cysto-epitheliomata,  glandular  and  papillary  cysts). 
Dermoid  cysts  may  so  develop  even  in  infancy  as  to  necessitate  an 
operation.  On  the  other  hand,  ovarian  cysts  have  been  developed 
at  an  advanced  age,  sisty-hve  to  seventy-five  years.  Some  curious 
cases  of  cysts  in  sisters  have  been  noted.  The  affection  is  often 
bilateral.  Scanzoni  has  attiibuted  an  aetiological  influence  to 
chlorosis  that  is  wholly  hypothetical. 

Symptoms. — The  beginning  is  marked  by  vague  disturbances, 
which  have  no  particular  character  and  are  a  mUd  form  of  those 
I  have  described  under  the  term  uterine  syndrome.  There  are 
first  some  simple  reflex  troubles  due  to  congestion  and  di-agging  of 
the  appendages.  Later,  there  are  added  the  symptoms  of  pressure 
upon  the  rectiim,  the  bladder,  or  of  the  nerves,  when  the  cyst  is 
included  below  the  peritonaeum.  But  these  phenomena  are  wanting 
in  the  gi'eat  majority  of  cases.  Then  to  the  latent  period,  or 
simply  metritic  (pseudo  metritis'),  succeeds  at  once  a  period  of 
tumefaction  in  which  the  abdomen  assumes  a  development  that 
becomes  more  and  more  marked.  At  the  same  time,  too,  the  health 
is  impaned  and  a  final  period  of  emaciation  precedes  the  ultimate 
accidents  that  cause  death,  if  art  does  not  intervene  in  time.    Two 


Ovarian  Cysts.  443 

piiases  in  the  evolution  of  the  cystic  tumor  must  be  distinguished, 
and  each  corresponds  to  physical  signs  that  are  radically  distinct : 
1st.  The  tumor,  small,  is  concealed  in  the  pelvis,  appreciable  only 
by  the  bimanual  exploration.  •2d.  The  tumor  has  become  abdo- 
minal and  can  be  easily  explored  through  the  abdominal  walls. 

1.  Pelvic  tumor. — Almost  always  as  soon  as  the  tumor  has 
acquired  a  size  double  or  treble  that  of  the  healthy  ovary,  its 
weight  causes  it  to  fall  into  Douglas'  cul-de-sac.  However,  in  cases 
where  a  retroverted  uterus  bars  the  way,  it  may  remain  fixed 
on  the  sides  or  in  front.  Bimanual  palpation  recognizes  its 
presence ;  its  situation  audits  connections  betray  its  ovarian  nature. 
It  is  most  often  hard,  from  the  small  size  and  the  tension  of  the 
sac,  rarely  elastic  or  irregular.  To  search  for  its  pedicle  Hegar's 
method  (drawing  down  the  uterus  with  forceps,  combined  with  rectal 
touch  or  bimanual  exploration)  is  very  usual.  When  the  tumor  is 
markedly  pedunculated,  it  is  very  mobile  and  can  only  be  felt  m 
vaginal  examination  by  pushing  it  from  above  downward  with  the 
other  hand.  When  it  is  included  in  the  broad  ligament,  it  may 
make  one  body  with  the  uterus,  but  between  this  organ  and  the 
cyst  a  slight  groove  may  be  found  by  examining  with  care.  It 
should  not  be  forgotten  that  in  such  a  case  the  uterus  is  deviated 
laterally,  anteriorly,  or  posteriorly.  In  the  papillary  cysts  the 
tumor  is  often  bilateral,  and,  very  exceptionally,  vegetations  can 
be  felt  on  its  surface ;  there  is  also  ascites  generally. 

I  have  already  indicated,  in  speaking  of  pathological  anatomy, 
the  existence  of  a  very  distinct  type  of  cystic  lesions  of  the  ovary 
that  I  have  proposed  to  call  cystic  disease.  It  is  characterized  by 
the  multiplicity  of  sacs,  by  their  small  volume,  which  usually  do 
not  permit  the  tumor  to  attain  a  size  exceeding  that  of  the  fist  or 
of  the  foetal  head,  and,  finally  by  their  frequent  bilateral  character. 
These  tumors,  from  their  moderate  dimensions,  remain  pelvic 
indefinitely.  On  bimanual  exploration  they  are  recognized,  either 
at  the  sides  of  the  uterus  or  behind  it  in  Douglas'  cul-de-sac,  where 
they  are  fixed  by  adhesions.  One  of  their  most  constant  symptoms 
is  menorrhagia. 

Abdominal  tumor. — The  possibility  of  perceiving  the  fundus  of 
the  tumor  at  a  certain  height  above  the  pelvis  completely  changes 
its  external  characters.  If  the  woman  is  very  obese,  or  if,  being 
nulliparous,  she  has  very  firm  and  contracted  abdominal  waUs, 
anaesthesia  is  very  useful.  By  palpation  of  the  abdomen,  globulajf 
tumor  is  felt  that  is  easily  outlined  above  and  at  the  sides,  more 
vaguely  below.  Irregularities  and  prominences  usually  announce 
a  polycystic  tumor.  The  resistance  is  more  elastic,  less  hard,  in 
proportion  as  the  tumor  is  larger.  Fluctuation,  that  it  was 
impossible  to  perceive  without,  becomes  marked  with  anaesthesia. 
Percussion  over  the  tumor  gives  an  obscure  dullness ;  it  is  necessary 


444  Orarion  Cysts. 

to  percus  ligbtlj'  to  avoid  the  intestiual  .souorousness  transmitted 
from  the  intestine.  This  resonance  from  contiguity  often  renders 
the  exact  limitation  of  the  cyst  by  percussion  deceptive. 

With  bimanual  examination,  the  uterus  is  most  often  found  in 
anteversion  a  little  deviated  to  the  side  opposite  the  cyst.  The 
cervix  is  di-awu  upward  and  sometimes  absorbed  by  the  unfolding 
of  the  vaginal  cul-de-sac.  By  the  sound  a  notable  elongation  of 
the  uterine  cavity  is  found.  Later  in  its  development,  the  cyst 
pushes  the  uterus  backward  (Peaslee).  Finally,  there  are  cases 
where  the  uterus  is  pushed  downward,  in  prolapsus.  In  large  cysts 
of  the  broad  ligament  the  uterus  may  be  wholly  displaced. 

When  the  cyst  has  attained  enormous  dimensions  the  abdominal 
walls  are  thin,  the  lina  alba  is  enlarged,  the  umbihcus  is  distended. 
It  is  only  with  ascites  that  the  umbilicus  becomes  prominent. 
Dilated  veins  ramify  over  the  abdominal  walls,  especially  m  the 
region  of  the  iliac  fossa?,  while  in  the  ascites  symptomatic  of 
cirrhosis  they  are  especially  \isible  in  the  supra-umbilical  region. 
"WTien  the  tumor  has  passed  the  umbilicus,  fluctuation  is  easily 
felt,  at  least  over  a  gi-eat  portion  of  the  tumor.  It  is  especially 
in  parovarian  cysts  with  thin  walls  that  it  is  very  distinct.  By 
determining  the  extent  of  repercussion  an  idea  can  be  gained  of  the 
size  of  the  sacs,  and  if  there  are  several  centers  of  fluctuation  it  can 
be  affirmed  that  the  tumor  is  polycystic.  Sometimes  it  is  more  of 
a  ^"ibration  than  a  true  fluctuation.  Sometimes,  generally  toward 
the  flanks,  solid  masses  are  found.  These  are  microcystic  agglome- 
rations, generally  areolar  and  colloid.  Percussion  defines  a 
dullness,  in-egularly  globular,  convex  above,  separated  by  a  clear 
zone  from  the  hepatic  dullness,  uioless  the  size  is  very  great.  All 
around  exists  the  intestiual  souorousness.  That  of  the  stomach 
may  be  much  diminished,  but  always  persists  in  the  epigastrium 
and  over  the  left  border  of  the  thorax.  Changes  of  position  are 
without  influence  on  the  dullness.  In  extreme  cases,  the  costal 
cartilages  and  the  sv-phoid  appendix  are  thi'own  outward,  the  hver 
is  pushed  into  the  concavity  of  the  diaphi-agm,  the  heai-t  is  pushed 
up,  the  abdomen  projects  into  the  thorax.  Pressure  on  the  vessek, 
aorta,  ciiu-al  arieries,  may  produce  vascular  souffles  that  have  no 
impoi*tance.  There  is  a  bruit  that  the  hand  perceives  better  than 
the  ear ;  it  is  when  a  certain  force  is  given  to  the  palpation  of  some 
tumors,  a  sound  as  of  cmshed  snow.  This  is  due,  according  to 
Olshauseu,  to  a  displacement  of  colloid  material,  either  fi-om  one 
cavity  into  another  or  at  the  surface  of  the  cyst  if  it  is  ruptured. 
I  believe  that  the  simple  rubbing  of  the  peritouieum  gives  the 
same  sensation,  and  that  it  is  difficult  to  accord  it  much  diagnostic 
value. 

The  disturbances  with  regard  to  menstmation  are  more  com- 
mon than  might  be  supposed  a  priori,  it  should  not  be  forgotten 


Ovarian  Cysts.  445 

that,  the  trouble  being  unilateral  most  frequent  in  large  cysts, 
the  healthy  ovary  is  sufficient  to  insure  the  regularity  of  menstru- 
ation. Sterility  will  be  certain  only  if  both  ovaries  are  attacked, 
and  it  is  well  known  that  ovarian  cysts  frequently  complicate 
pregnancy.  It  has  been  noted  that  menorrhagia  is  not  rare  in 
case  of  cysts  included  in  the  immediate  vicinity  of  the  uterus. 
After  the  menopause,  congestion  of  the  uterus  may  cause  the 
appearance  of  more  or  less  irregular  sanguineous  flow.  Sometimes, 
under  the  influence  of  ovarian  tumors,  as  well  as  uterine  growths, 
a  reflex  influence  affects  the  breasts  producing  sweUings  and  a 
pigmentation  of  the  areola,  as  in  pregnancy.  Secretion  of  milk  has 
been  noted  even  in  young  gu'ls. 

It  is  necessary  to  distinguish  the  pressure  effects  on  the  early 
stages  of  the  growth,  which  are  manifest  only  when  it  is  included 
in  the  pelvic  cavity  (cysts  included  in  the  broad  ligament  and  retro- 
peritoneal) and  the  disturbances  from  pressure  developed  at  an 
advanced  period  when  the  cyst  acts  by  its  weight  and  its  volume 
more  than  by  its  connections.  Pressure  upon  the  bladder  often 
causes  incontinence  of  urine,  in  the  earlier  history  of  broad  liga- 
ment cysts;  at  other  times,  tenesmus  and  dysuria.  Very  sharp 
pains  from  compression  of  the  nerves  may  be  present  under  the 
same  circumstances.  More  frequently  it  is  only  in  the  latter 
periods  of  the  development  of  the  tumor  and  when  it  distends  the 
abdomen  that  the  disturbances  due  to  pressure  become  pronounced. 
There  are  then  seen  vesical  symptoms,  constipation,  anorexia, 
vomiting  and  marasmus.  In  case  of  excessive  development  there 
is  dyspnoea  and  cyanosis  from  compression  of  the  thorax.  Another 
cause  of  dyspnoea  that  is  often  unrecognized  occurs  early  from 
pressure  upon  the  ureters  and  its  conseqiient  chronic  uraemia.  The 
cardiac  affections  which  have  been  noted  in  such  cases  depend 
indirectly  on  the  renal  lesion. 

When  the  cyst  acquires  some  volume  the  cylindrical  epithelium, 
which  forms  a  smooth  protection,  desquamates  in  places  and 
adhesions  are  produced.  These  are  especially  common  at  the 
anterior  walls.  This  work  of  partial  peritonitis  occurs  without 
febrile  reaction,  unless  induced  by  an  accident  to  the  cyst — torsion 
or  rupture. 

The  general  health  is  rapidly  impaired.  Two  principle  factors 
contribute  to  produce  the  emaciation  of  these  patients.  The  com- 
pression of  the  different  portions  of  the  digestive  tract,  added  to 
the  reflex  dyspepsia,  prevents  repair  of  the  incessant  losses  of  the 
organism ;  the  compression  of  the  ureters  contributes  to  the  denu- 
trition  Avithout  causing  loss  of  albumen,  and  all  the  other  pressures 
which  cause  suffering  and  deprive  the  patient  of  sleep  act  in  the 
same  way.  The  women  then  become  very  much  emaciated,  but 
without  the  so-called  pretended  ovarian  facies  that  some  authors 


446  Ovarian  Cysts. 

liave  tried  to  give  an  almost  pathognomonic  value,  having  any 
special  signification. 

Aceide7its. — Injiaminatloii ,-  Suppuratwn. — Temporary  elevation  of 
the  temperature  and  sensitiveness  of  the  abdomen  in  a  woman 
affected  with  an  ovarian  cyst  are  the  indices  of  an  acute  inflam- 
mation, either  around  the  cyst  or  witliin  it,  but  it  is  only  suppu- 
ration of  the  cyst  that  gives  rise  to  regular  attacks  of  intense 
fever  with  chills  and  sweat,  accompanied  with  acute  local  pain.  In 
the  anamnesis  there  is  commonly  found  an  explanation  of  these 
symptoms — contusion,  puncture,  torsion  of  the  pedicle. 

Torsion  of  the  jiedide. — If  the  torsion  of  the  pedicle  occurs  slowly 
a  progressive  diminution  of  the  tumor  may  result.  But  if  it  occurs 
suddenly  there  are  sharp  pains,  and  symptoms  of  peritonaeal 
reaction  are  immediately  developed  and  foUowed  by  a  peritonitis 
of  variable  intensity.  This  may  be  rapidly  fatal  or  take  on  a 
dropsical  character.  These  accidents  have  been  seen  to  disappear 
in  a  few  days,  and  Olshauseu  believes  these  may  be  temporary 
torsions.  Finally  the  symptoms  may  continue  in  consequence  of 
the  resorption  of  the  materials  thrown  out  by  slow  death  of  the 
tumor,  and  the  patient  may  die  in  marasmus  and  cachexia. 
Eupture  of  the  cyst  often  coincides  with  torsion  of  the  pedicle. 
This  is  sometimes  complicated  by  considerable  internal  hemor- 
rhage, the  arterial  blood  continuing  to  flow  while  the  veins  are 
effaced  by  torsion.  These  haemorrhages  add  an  acute  anaemia  to 
the  ah-eady  grave  condition  of  the  patient.  The  signs  of  peritonitis 
soon  appear  around  the  sac  and  the  formation  of  extensive  adhe- 
sions is  one  of  the  most  constant  effects  of  tortion. 

Rupture  of  the  cyst. — The  rupture  of  smaU  cysts  due  to  follicular 
dropsy  appear  to  be  quite  frequent  and  without  any  important 
effects.  With  regard  to  large  cysts  their  rupture  is  caused  either 
by  traumatisms  or  by  fatty  degeneration  from  thrombosis.  This 
accident  occurs  more  frequently  in  gelatinous  cysts ;  torsion  of  the 
pedicle  often  preeeds  it.  The  erosion  of  the  sac  by  papillary  vege- 
tations may  also  be  a  cause.  The  perforation  may  occur  either 
into  the  peritonaeal  cavity  or  into  a  contiguous  organ.  The  first  is 
the  most  frequent.  It  may  be  followed  by  resorption  of  the  liquid 
without  much  reaction,  if  the  liquid  is  not  too  irritating,  as  in 
serous  cysts.  Death  may  occur  so  quickly  that  it  seems  due  to 
poisoning  from  resorption  of  morbid  products;  generally  it  is 
preceded  by  the  symptoms  of  an  acute  peritonitis. 

Sudden  disappearance  of  the  tumor,  the  change  in  the  form  of 
the  abdomen,  the  symptom  of  a  free  collection  in  its  ca^'ity,  that 
the  hand  must  displace  to  reach  the  remains  of  the  cyst,  such  are 
the  pathognomonic  symptoms  of  the  accident  that  is  sometimes 
announced  to  the  patient  by  a  peculiar  sensation  of  faintness  and 
often  by  an  acute  pain.     If  the  patient  sur%'ives  she  may  present 


Ovarian  Cysts.  447 

later  on  the  signs  of  a  peritonseal  metastasis  with  ascites.  Earely, 
the  rupture  occurs  in  a  latent  manner  and  not  announced  by  any 
symptoms  that  attract  attention.  The  effusion  may  be  isolated  by 
false  membranes  and  form  a  new  intra-peritonffial  cystic  cell.  A 
diuresis  and  an  abundant  diaphoresis  have  been  noted  in  the  case 
of  intra-peritonaeal  rupture  of  ovarian  cysts.  Anasarca  has  also 
l)een  seen.     Ivustner  has  drawn  attention  to  peptonuria. 

Eupture  into  the  intestines  generally  takes  place  into  the  rectum 
or  colon ;  in  the  case  of  suppuration  of  the  cyst  a  great  relief  results 
at  first,  but  rarely  this  goes  on  to  recovery ;  on  the  contrary,  fecal 
material  may  infect  the  cavity  of  the  cyst  and  produce  a  hectic 
condition.  The  stomach  and  the  small  intestine  have  been  the 
seat  of  evacuation  in  a  few  cases.  External  rupture  by  an  erosion 
of  the  abdominal  wall  has  been  observed.  It  is  quite  favorable. 
Eupture  into  the  vagina  or  bladder  is  rare.  Finally,  under  the 
head  of  rupture  we  may  include  the  evacuation  by  the  tubes  after 
the  formation  of  profluent  tubo-ovarian  cysts. 

Internal  strangulation  may  occur  during  the  involution  of  the 
cyst  either  by  excessive  pressure  on  the  intestine,  by  the  intestine 
becoming  twisted  around  the  pedicle  or  by  the  effect  of  a  peritonseal 
adhesion.  The  diminution  of  the  tumor  by  a  puncture,  in  this  last 
case,  may  have  unfortunate  results.  Pleural  complications  have 
been  noted. 

Prognosis. — When  tumors  of  the  ovary  have  acquired  such  a  size 
that  the  general  health  is  affected,  the  probable  duration  of  life  for 
the  patient  certainly  does  not  exceed  two  years  (Spencer  Wells).  It 
is  important,  however,  to  note  that  in  certain  exceptional  cases  the 
progi'ess  of  the  disease  may  be  exceedingly  slow.  This  is  usually 
the  case  with  dermoid  cysts.  Hyaline  parovarian  cysts  and  uni- 
locular cysts  of  the  broad  ligament  may  rupture  into  the  peritonaeum 
several  times  successively  and  after  each  I'upture  there  is  a  long 
period  of  relief.  On  the  contrary,  proliferous  cysts  sometimes 
take  on  a  rapid  development  after  having  long  remained  stationary. 
Hyaline  parovarian  cysts  of  the  broad  ligament  grow  rapidly. 
Papillary  cysts  may  cease  growing  for  a  long  period ;  but  when 
ascites  appears,  showing  that  the  vegetations  have  perforated  the 
sac,  a  fatal  termination  is  near. 

Spontaneous  cure,  relative  or  absolute,  is  not  impossible.  Intra- 
peritonseal  rupture  sometimes  brings  about  the  cure  of  parovarian 
cysts.  Slow  torsion  of  the  pedicle  exceptionally  induces  atrophy  of 
proliferous  cysts. 

Death  is  the  usual  result  of  the  development  of  the  cyst  if  surgery 
does  not  intervene.  Marasmus,  peritonitis  and  embolism  are  the 
three  principal  causes  of  death.  Suppuration  of  the  cysts  in  con- 
sequence of  repeated  punctures  or  of  untimely  treatment,  was 
formerly  frequent. 


448  Orariaii  Cysts. 

What  is  the  value  of  ascites  in  a  prognostic  point  of  view  ?  It  is 
an  unfavorable  circumstance,  for  it  is  especially  met  either  in 
papillary  cysts  that  have  passed  the  cyst  limits,  or  in  glandular 
cysts  from  rapture  or  from  torsion  of  the  pedicle.  However, 
numerous  observations  have  shown  that  this  complication  is  not 
absolutely  gi'ave. 

A  question  that  is  still  obscure  is  that  of  the  benign  or  of  the 
malignant  character  of  papillary  cysts.  Eecoveries,  after  their 
extirpation  are  common.  On  the  other  hand,  the  hability  to 
metastases,  or  even  to  general  invasion  of  the  peritonaeum  with 
papUlary  cysts  in  malignant  form,  should  make  the  prognosis 
guarded.  It  might  be  said  that  we  have  here  an  element  which 
transcend  the  powers  of  the  microscope.  It  seems  that  the  extreme 
histological  instabihty  of  these  neoplasms,  the  easy  transformation 
of  theii-  cylindrical  epithelium  into  malatypical  or  atypical  epi- 
thelium, places  these  cysts  in  a  pei-petual  state  of  malignant 
imminence,  as  might  be  said. 

Glandular  cysts  may  present  a  caijcerous  degeneration.  Hofmeir 
and  Cohn  have  pointed  out  the  racemose  appearance  of  the  cystic 
masses  that  sometime  indicate  this  malignant  transformation.  The 
cUnical  characters  leave  no  doubt  in  such  cases.  There  are  rapid 
and  sudden  developments  in  a  tumor,  ah'eady  long  in  existence, 
emaciation  and  cachexia,  multiple  adhesions,  especially  in  the 
1  pelvic  cavity,  oedema  of  the  lower  hmbs  and  of  the  abdominal 
walls  out  of  proportion  to  the  size  of  the  tumor  and  the  quantity 
of  the  ascitic  effusion,  pliu-isy,  etc.  The  prognosis  of  malignant 
tumors,  characterized  by  these  symptoms,  is  veiy  unfavorable. 
However,  as  permanent  good  has  resulted  in  cases  apparently 
desperate,  it  appears  proper  to  operate  whenever  there  is  hope. 
Leopold,  owing  to  the  possibility  of  this  degeneration,  advises,  as  a 
rule,  the  removal  of  an  ovarian  tumor  as  soon  as  it  appears, 
especially  if  it  is  bilateral. 

Diagnosis. — A.  Pelvic  tumors. — In  the  early  stage  of  development 
of  ovarian  cysts  it  is  very  difficult  to  distinguish  them  fi'om  other 
tumors  arising  at  the  side  of  the  utems.  A  sessile  cyst,  of  the 
broad  ligament,  may  be  simulated  in  the  beginning  by  the  inflam- 
matory nucleus  of  perimetro-salpingits.  The  history,  the 
progi'ess,  the  coexistence  of  inflammation  of  the  tubes  and  of  the 
uterus,  wiU  guard  against  error.  These  tumors  are,  besides  quite 
limited,  more  sensitive  to  pressm-e  and  subject  to  rapid  variations 
in  volume.  A  pelvic  luematocele,  of  smaU  size,  is  fluctuating  at 
the  onset  but  does  not  give  the  impression  of  an  encapsulated 
tumor,  especially  at  the  sides  where  it  is  always  a  httle  diffuse.  In 
its  course  the  tumor  becomes  hard.  Finally,  its  mode  of  appear- 
ance, the  intense  peritonaeal  reaction  in  the  beginning,  are  very 
characteristic.     The  extraperitoneal  variety  may  be  very  difficult 


Ovarian  Ci/sts.  449 

to  distiuguish  other  than  by  its  clinical  course  -nhich  tends  to  its 
gradual  resoi-ption.  Tumors  of  the  tubes,  especially  hydrosalpiri3L, 
may  give  rise  to  considerable  hesitation.  The  bilateral  character 
of  the  lesion  is  in  theii-  favor ;  there  are  cases  when  the  diagnosi^ 
can  he  fully  made  only  after  the  laporotomy  that  is  indicated  in 
both.  Extrauterine  pregnancy,  in  its  beginning  offers  few  dis- 
tinctive signs,  although  it  ordinarily  causes  amenorrhoea  and  a 
congested  state  of  the  genital  mucosa  ;  later  it  presents  the  special 
characters  described  in  another  chapter.  Eetrofiexion  of  the 
gravid  uterus,  at  the  third  or  fourth  month,  could  be  suspected 
only  if  there  are  the  signs  of  a  beginning  pregnancy  and  if  the 
tumor  is  situated  in  the  posterior  cul-de-sac  and  gives  rise  to 
symptoms  of  compression  (retention  of  urine,  constipation),  finally, 
if  it  has  a  soKd  consistence  and  is  continuous  with  the  cervix, 
which  is  carried  forward,  attempts  at  reduction  will  dispel  the  doubt. 
The  exact  situation  of  the  uterus  must  'always  be  sought  before 
deciding  on  a  tumor  independent  of  that  organ.  I  need  only 
mention  the  possibility  of  being  deceived  by  fecal  tumors. 

B.  Abdo7?unal  tumor. — Pregnancy  should  be  placed  fii-st,  for  of 
all  errors  mistaking  pregnancy  for  morbid  gi'owth  is  the  most 
unfortunate.  It  is  especially  when  there  is  a  complication  of 
hydramnios  that  this  mistake  is  most  Ukely  to  occur,  for  then  one 
can  neither  palpate  the  foetus  nor  hear  the  sounds  of  the  heart.  To 
avoid  the  opposite  error  and  not  to  mistake  a  cyst  for  a  gi-avid 
utems,  the  probable  signs  must  never  be  rehed  on,  but  only  the 
positive  signs  sought  for.  AmenoiThosa,  swelling  of  the  breasts  and 
even  a  sensation  of  foetal  movements  (produced  by  borborygmus"! 
may  exist  in  ovarian  tumors.  The  perception  by  the  surgeon  of 
these  movements,  the  sounds  of  the  foetal  heart,  the  positive 
detection  of  foetal  parts,  the  perception  of  contraction  in  gravid 
uteras,  ballottement,  and  filially,  toward  the  end  of  pregnancy,  the 
engagement  of  a  foetal  part  in  the  pelvic  cavity,  will  alone  make 
the  diagnosis.  The  employment  of  the  uterine  sound  is  dangerous 
and  useless.  It  should  be  remembered  that  there  may  be  preg- 
nancy and  cyst  together,  a  condition  difficult  of  diagnosis.  Attempt 
should  then  be  made  to  distinguish  the  fluctuating  parts  and  the 
position  of  the  foetus  by  the  aid  of  auscultation  and  palpation.  It 
is  certainly  more  serious  to  mistake  a  gravid  uterus  for  a  cyst  than 
to  commit  the  opposite  eiTor,  and  in  doubt  it  is  better  to  temporize. 
It  is  useless  to  say  that  exploratory  puncture  is  here  incomparably 
more  dangerous  than  exploratory  incision. 

Ascites  may  only  ;;imulate  a  very  large  cyst,  filling  the  abdomen 
and  of  in  distinct  limits.  I  will  recall  the  distinctive  signs  of 
effusion  of  liquid  into  the  peritonseum ;  the  abdomen  is  flattened, 
less  pointed  than  in  case  of  a  cyst,  the  dullness  obtains  over  the 
lower  level  paiis,  and  is  limited  by  a  concave  line  above  (Figs.  24"2 


4o0 


Ovarian  Cysts. 


iuid  243).  In  the  lateral  tlecubitus  the  dullness  gravitates  to  the 
lower  side  while  there  is  resonance  on  the  opposite  side  that  did 
not  exist  before.  This  displacement  is  quite  characteristic.  But 
there  are  more  difficult  cases,  where  the  ascites  develops  rapidly, 
the  abdomen  is  tense,  the  skin  is  smooth  and  gives  a  sensation  of 
undulation.  The  dullness  then  may  not  be  systematically  dis- 
tributed ;  the  contents  may  even  be  displaced  with  difficulty  on 
changing  position  (Duplay).  But  then,  the  excessive  rapidity  of 
the  development  of  the  abdomen,  the  habitual  cedemea  of  the 
lower  limbs,  the  concomitant  disturbance  dependent  on  the  principal 
disease,  finally,  the  absence  of  a  limited  tumor  at  a  previous 
period,  constitute  the  guiding  facts.  One  sign  which  should  always 
be  sought,  is  the  mobility  of  the  uteras,  which  persists  in  ascites 
and  which  is  abolished  in  large  cysts.  The  state  of  the  \iscera, 
which  in  diseased  conditions  frequently  give  rise  to  ascites  (heart, 
Uver),  should  always  be  examined. 


Fig.  242. — Topography  of  the  dullness 
of  ascites.  I,  intestinal  sonorousness;  L, 
hepatic  dullness;  A  A,  dullness  of  the 
flanks. 


Fig.  243. — Topography  of  dullness  in  an 
ovarian  cyst.  I,  intestinal  sonorousness;  L, 
hepatic  dullness;  OT,  dullness  over  the 
cvst. 


It  is  especially  the  ascites  symptomatic  of  tuberculous  or  can- 
cerous peritonitis  that  may  give  rise  to  difficulties  of  diagnosis,  for 
the  dropsy  of  the  peritonaeum  may  be  encysted  by  adhesions.  In 
the  first  ease  the  concomitant  symptoms  of  intestinal  and  pulmo- 
nai-y  tuberculosis,  the  irregularity  of  the  abdomen,  due  to  the 
meteorism  induced  by  adhesions,  the  cry  intestinal  (Gurneau  de 
Mussy)  provoked  by  palpation  ;  in  the  ease  of  cancer,  the  presence 
of  irregular  and  ligneous  cakes  in  the  omentum,  theii'  fusion  with 
the  contiguous  parts,  the  rapidly-developed  cachexia,  such  are  the 
principal  elements  of  the  diagnosis. 


Ovarian  Cysts.  451 

Puncture  may  be  of  great  service  in  these  cases  by  permitting 
examination  of  the  hquid,  and  also  in  facilitating  palpation  of  the 
abdomen  by  relieving  tension.  However,  to-day  it  is  not  usually 
practiced,  for  it  has  many  disadvantages.  If  it  is  employed  it 
should  be  undertaken  with  great  care.  Puncture  with  complete 
evacuation  is  infinitely  less  grave  in  a  large  tumor  than  in  a  small 
one,  for  the  marked  collapse  of  the  empty  sac  then  tends  to  prevent 
the  effusion  of  liquid  into  the  peritonseum.  The  place  for  puncture 
is  the  middle  of  the  line  comprised  between  the  linea  alba  and  the 
antero-superior  iliac  spine,  or  in  the  linea  alba  itself.  The  bladder 
should  be  pre^dously  emptied  with  the  catheter,  and  complete 
dullness  of  the  point  of  puncture  must  be  assured. 

The  examination  of  the  liquid  mthdrawn  often  establishes  the 
diagnosis.  If  it  be  viscous,  colored  brown,  green,  or  black,  these 
characters  point  to  a  cyst.  A  perfectly  clear  liquid,  not  coagulated 
by  heat,  may  be  from  a  parovarian  hyaline  cyst  of  the  broad 
ligament  or  from  a  hydated  cyst.  But  there  are  cases  where  this 
examination  leaves  doubt,  where  the  liquid  is  thin,  lemon  or  amber 
color,  or  only  sanguinolent ;  both  ascites  and  some  cysts  present 
these  characters.  I  have  already  spoken  of  diagnostic  significance 
of  paralbumen. 

Palpation  of  the  aodomen  after  punctiire  affords  valuable 
information ;  it  permits  recognition  of  the  ovarian  tumor  and  also 
permits  the  determination  of  the  other  changes  in  the  viscera  that 
are  liidden  by  the  accumulation  of  liquid.  It  should  not  he 
forgotten  that  ascites  may  complicate  a  cyst,  either  ruptured  or 
papillary,  with  external  vegetations.  There  may  then  be  a  special 
sensation  of  ballottement  as  if  the  cyst  floated  in  the  ascites. 

Puncture  of  a  cyst  is  not  an  inoffensive  operation  even  when 
made  with  the  greatest  precautions.  An  incomplete  evacuation 
may  be  followed  by  a  flow  of  liquid  into  the  abdomen  and  fatal 
peritonitis.  The  neglect  of  antiseptic  precautions,  or  an  unknown 
circumstance,  may  cause  suppuration  of  the  cyst.  This  fact  has 
been  especially  noted  mth  regard  to  dermoid  tumors.  Grave 
hseniorrhages  have  been  seen  from  a  wound  of  the  large  vessels  of 
the  abdominal  walls  or  of  the  tumor.  Finally,  the  weakening  in 
the  cyst  wall,  which  may  result  from  the  puncture,  favors  the  pro- 
trusion of  papillary  vegetations  and  peritonseal  infection. 

Uterine  fibroids  have  often  been  simulated  by  oligo-cystic  tumors 
with  gelatinous  contents.  This  error  is  especially  liable  to  occur 
when  the  absence  of  pedicle  gives  to  solid  tumors  the  movements 
impressed  on  the  uterus.  Anaesthesia  often  permits  the  discovery 
of  fluctuation  where  it  escapes  without  notice.  Bimanual  exami- 
nation is  necessary  to  precisely  determine  the  connections  with  the 
uterus.  Finally  a  very  marked  enlargement  of  the  uterine  cavity 
detected  with  the   sound    is   in  favor  of  fibroma,  "although    an 


•l52  Ovarian  Cysts. 

elongation  of  two  or  thi'ee  centimetres  may  be  produced  by  the 
jiscent  and  traction  of  the  ovarian  tumor.  Fibro-cystic  tumors  of 
the  uterus  are  especially  lialjle  to  mislead. 

Hiematometria  is  distinguished  by  its  situation  and  its  special 
causes. 

Vesical  distention  has  been  the  cause  of  errors  that  the  surgeon 
may  avoid  by  catheterizing  the  patient  himself.  Renal  tumors, 
hydronephrosis,  hydatid  cysts,  etc.,  have  given  rise  to  confiasion. 
Great  care  should  be  used  to  learn  if  the  tumor  is  fixed  in  the 
hypochoudrium,  if  its  lower  border  is  free,  permitting  the  hand  to 
pass  below  it,  and  if  the  intestine,  particularly  the  colon,  can  be 
detected  between  the  tumor  and  the  abdominal  wall.  When  the 
tumor  fills  the  whole  abdomen  these  signs  are  absent.  Even  then, 
however,  the  anterior  situation  of  the  colon  preserves  its  import- 
ance (Nelaton).  Pawlik  attaches  great  value  to  the  persistence  of 
the  characteristic  form  of  the  kidney  found  after  puncture.  The 
development  of  a  tumor  datmg  from  infancy  is  in  favor  of  hydro- 
iiephi-osis  and  of  cancer  of  the  kidney.  The  presence  of  pus  or  of 
blood  in  the  urine  is  significant.  Urea  may  be  wanting  in  hydro- 
nephrosis and  is  found  in  ovarian  cysts ;  the  same  is  true  of  uric 
acid. 

I  only  mention  tumors  of  the  liver  and  of  the  spleen  on  account 
of  their  variety.  Tumors  of  the  mesentery  and  of  the  omentum 
and  eehinococeus  of  the  abdominal  cavity  are  often  only  recognized 
by  exploratory  puncture.  Tumors  of  the  abdommal  wall  have 
caused  errors  that  may  be  avoided  by  examination  under  anaes- 
thesia. 

Tympanitis,  associated  with  partial  contraction  of  the  abdominal 
muscles  and  a  local  deposit  of  fat,  gives  rise,  especially  among 
hysterical  women,  to  curious  conditions  simulating  tumor.  The 
best  means  of  avoiding  mistakes  among  such  women  is  careful 
bimanual  examination  under  anesthesia. 

Exploratory  incision. — When  at  last  all  other  means  of  exploration 
fail,  are  we  authorized  in  opening  the  abdomfen  to  insure  the 
diagnosis  of  the  tumor,  and  to  operate  at  the  same  time  if  possible  '? 
Lawson  Tait  always  substitutes  incision  for  exploratory  puncture. 
I  am  also  a  thorough  partisan  of  exploratory  incision  where  it 
appears  to  be  the  only  means  of  ensuring  diagnosis. 

Dia<j)iosis  of  the  varietti  of  the  cyst. — I  will  sum  up  briefly,  as 
follows :  A  very  large  tumor,  with  projections  that  are  of  unequal 
consistency,  is  a  glandular  cyst.  The  presence  of  ascites  (in  the 
absence  of  the  symptoms  of  rupture),  the  sensation  of  irregular 
and  papillary  masses  in  Douglas  cul-de-sac,  the  bilateral  character, 
^vill  suggest  a  papillary  cy.st.  Fluctuation,  easily  perceived  and 
superficial  over  the  whole  extent  of  the  tumor,  the  slow  progi-ess, 
the  almost  perfect  preservation  of  the  general  health  even  with  a 


Ovarian  Cysts.  453 

large  tumor,  the  close  connections  with  the  uterus,  or  a  cyst 
apparently  included  in  the  broad  ligament  or  retained  by  a  short 
pedicle,  such  are  the  characters  of  an  hyaline  parovarian  cyst.  The 
possibility  of  perceiving  the  ovary  and  tube  at  the  site  of  the  tumor 
has  been  noted  in  such  cases  as  pathognomonic.  For  the  dermoid 
cysts  there  has  been  indicated  the  possibility  of  making  impressions 
in  the  tumor  as  in  a  mass  of  putty. 

Diagnosis  of  adhesions. — For  the  recognition  of  the  parietal  adhe- 
sions Spencer  Wells  notes  whether  changes  in  the  position  of  the 
patient  or  respiratory  movements  affect  the  tumor.  By  displacing 
the  abdominal  walls  over  the  tumor  it  can  be  seen  if  the  umbilicus 
glides  over  it  easily  or  if  friction  is  perceived  as  an  indication  of 
adhesive  peritonitis.  With  a  tumor  which  has  long  presented 
very  large  dimensions,  there  is  strong  probability  of  adhesions  to 
the  anterior  wall  or  to  the  omentum,  unless  there  may  have  been  a 
certain  degree  of  ascites.  Adhesions  to  the  viscera  may  be  sus- 
pected if  there  have  been  symptoms  of  acute  peritonseal  inflam- 
mation in  consequence  of  puncture,  of  torsion  of  the  pedicle,  or  of 
rupture. 


CHAPTER  XXXII. 


TREATMENT   OF   OVARIAN   CYSTS. 

I  shall  not  dwell  on  medical  treatment,  it  is  resi^onsible  for  the 
death  of  many  women  by  preventing  early  operation.  The  only 
rational  internal  treatment  is  the  administration  of  tonics,  sto- 
machics and  mild  laxatives.  Electrolysis,  which  has  been  so  abused 
in  gynaecology,  is  here  both  dangerous  and  useless.  Every  cyst  of 
the  ovary  when  once  discovered  should  be  removed  if  possible. 
Puncture  thi'ough  the  abdominal  wall  has  been  also  employed,  not 
as  a  curative  treatment  but  as  a  paUiative.  It  becomes  a  necessity 
in  cases  of  excessive  pressure  or  in  tumors  that  should  not  be 
operated.  Puncture  of  the  cyst  without  absolute  necessity,  and 
when  it  is  possible  to  extirpate  it,  is  ahvays  bad  practice.  The 
puncture  is  generally  made  through  the  abdominal  wall,  but 
puncture  through  the  vagina  has  also  been  made,  although  it  is 
even  more  dangerous.  Puncture  tlii'ough  the  rectum,  which 
Tavignot  recommended,  is  a  detestable  operation. 

Injections  of  iodine  has  scarcely  any  partisans  to-day,  and  was 
serviceable  only   at  an   epoch  when  ovariotomy  was   considered 


454  Ovarian  Cysts. 

dangerous.  Drainage  after  puncture  or  incision  was  at  the  same 
period  applied  to  cysts  in  which  extii'pation  woukl  have  heen  easy. 
Drainage,  to-day,  is  only  made  for  the  remains  of  a  sac  that  could 
not  be  entu-ely  extirpated,  or  in  a  suppurating  cyst  that  cannot  be 
operated  and  which  spontaneously  opens  externally. 

Ovariotomy. — Ephraim  MacDowell  made  the  first  ovariotomy 
for  cyst  of  the  ovary  in  1809.  A  number  of  isolated  facts  followed 
■with  varjdng  success  until  a  few  prominent  operators  began  to 
pubUsh  series  of  cases  with  a  considerable  proportion  of  recoveries. 
At  this  time  the  appearance  of  antiseptic  methods  introduced  a 
new  era,  and  the  operation  passed  from  the  hands  of  a  few  eminent 
specialists  into  those  of  all  surgeons. 

General  indications.  —  At  present  these  can  be  considerably 
abridged,  for  many  points  wliich  have  been  contested  are  settled 
to-day.  At  the  present  time,  then,  we  can  say  that  laparotomy  is 
necessary  as  soon  as  the  cyst  becomes  by  its  volume  a  source  of 
trouble  to  the  patient  or  an  imminent  cause  of  danger  to  life.  As 
soon  as  a  commencing  tumor  of  the  ovary  is  recognized  it  should 
be  removed ;  first,  because  the  operation  is  in  itself  less  serious 
then,  since  only  a  small  incision  is  requked  and  there  are  no  marked 
adhesions;  in  the  second  place,  because  the  prospective  dangers  of 
inflammation,  of  rupture,  or  of  torsion  of  the  pedicle,  are  avoided ; 
finally,  and  especially  because  every  cyst  of  the  ovary  is,  so  to 
speak,  a  neoplasm  of  unstable  equilibrium  between  a  lienign  and  a 
malignant  character. 

The  age  of  the  subject  should  not  be  a  contraindication.  Very 
young  children  have  been  operated  on  with  success,  and  on  the 
other  hand  very  aged  women  have  been  cured.  It  is  necessary, 
however,  to  be  guarded  against  the  unfortunate  effects  of  a  pro- 
longed decubitus  (hypostatic  pulmonary  congestion,  bed  sores,)  by 
lifting  the  patient  up  in  a  sitting  position  at  an  early  date. 

Operative  technique  of  ovariotomy. — Pedunculated  cysts. — I  refer  for 
the  preUmiuary  precautions  to  what  I  have  ah-eady  presented  on 
this  subject.  Many  surgeons  proceed  to  an  ovariotomy  only  when 
surrounded  by  a  considerable  armamentarium.  There  is  reason,  I 
beHeve,  in  limiting  the  number  of  instruments  employed,  to  reduce 
to  the  smallest  possible  degree  the  chances  of  infection.  It  is 
sufficient  to  have,  good  knives,  dissecting  forceps,  a  female  sound, 
a  male  sound,  a  grooved  director,  scissors,  one  pair  curved  on  the 
edge,  some  ordinary  hiemostatic  forceps,  long  forceps  for  adhesions, 
straight  and  curved,  two  Nekton's  cyst-forceps,  one  volsella,  one 
trocar,  one  pair  of  needle  forceps,  needles,  and  one  blunt  needle  in 
a  handle ;  finally,  catgut,  silk  and  compress-sponges.  All  these 
instruments  should  be  exclusively  reserved  for  laparotomies,  and 
should  have  been  heated,  as  I  have  said,  in  the  sterilizer,  at  140^  C. 
They  should  be  placed  near  the  operator's  hand  in  a  flat  basin 


Ovarian  Cysts.  455 

filled  with  carbolized  water  (2-100.)  It  is  well  to  re&erve  a  table 
near  by  for  supplementary  instruments,  for  unforseen  needs.  As  I 
have  renounced  the  use  of  sponges  I  do  not  fear  their  loss  in  the 
abdominal  cavity,  for  the  compresses  I  employ  always  have  one 
extremity  outside  the  wound.  The  precaution  of  counting  the 
forceps  is  wise.  It  is  sufficient  to  keep  a  close  watch  on  these 
instruments. 

The  number  of  assistants  should  be  as  limited  as  possible  :  one 
for  the  chloroform,  one  to  thread  and  pass  the  needles  or  the 
ligatures  (which  are  cut  in  advance  and  kept  in  a  carbolic  or  weak 
sublimate  solution) ;  a  thkd  experienced  assistant  is  sufficient  to 
assist  the  surgeon.  He  should  stand  to  the  left  of  the  patient, 
while  the  one  in  charge  of  the  sutures  is  placed  to  the  right  and 
consequently  on  the  surgeon's  left,  sufficiently  close  to  pass  the 
sutures  directly.  No  one  should  be  given  the  right  to  touch  any 
object  used  for  the  operation  except  the  assistants.  If  an  instrument 
falls  on  the  floor  it  should  not  be  used  again. 

The  operation  can  be  divided  into  four  stages : 

FiKST  Stage. — Opening  the  abdomen. — It  is  better  to  begin  with 
an  opening  of  medium  size  and  enlarge  it  later  on  if  necessary. 
While  the  assistant  places  his  index  finger  at  the  umbilicus  and 
draws  the  skin  slightly  upward,  the  surgeon  makes  an  incision  of 
ten  centimetres  with  a  strong  convex  knife  on  the  linea  alba  down- 
ward to  near  the  symphysis.  The  skin  and  cellular  tissue  being 
quickly  divided,  attempt  is  made  to  find  the  line  between  the  recti 
muscels  at  the  upper  part  of  the  wound.  The  opening  of  their 
sheath  is  a  disadvantage  of  little  importance.  Immediately  after, 
the  fascia  transversalis  and  the  subperitonseal  fat  are  reached. 
■The  latter  must  not  be  mistaken  for  the  great  omentum.  The  fatty 
bodies  are  incised,  and  excised  if  necessary,  and  the  peritonaeum  is 
reached.  Before  opening  it  complete  hsemostasis  should  be  ensured 
by  placing  two  or  three  forceps  on  the  bleeding  points.  The  peri- 
tonseum  is  seized  with  the  forceps  in  the  upper  part  of  the  wound, 
then  a  small  buttonhole  is  made,  a  grooved  director  is  introduced 
and  the  peritonaeum  is  incised,  either  with  a  knife  or  with  the 
scissors.  Danger  of  wounding  the  bladder  is  prevented  by 
uplifting  the  peritonteum  with  the  grooved  sound.  In  rare  eases 
the  adhesion  of  the  peritonaeum  to  the  wall  of  the  cyst  is  such  that 
distinction  is  impossible.  The  incision  should  then  be  prolonged 
above  to  arrive  at  a  point  where  the  peritonaeum  is  free,  then  to 
detach  it  from  above  downward.  This  is  infinitely  better  than  to 
enter  the  cyst  immediately  and  detach  it  by  traction  on  its  internal 
surface. 

Second  Stage. — Detachment  of  the  adhesions. — A.  Adhesions  to 
the  abdominal  wall. — The  right  hand  is  introduced  flat  in  the 
abdominal  wound,  and  proceeds  to  detach  the  adhesions  by  degrees 


466  Ovarian  Cysts. 

to  the  right  and  to  the  left  as  far  as  it  can  go.  Those  which  are  too 
solid  to  give  way  to  simple  pressure  are  easily  perceived  and  they 
are  left  until  after  evacuation  of  the  cyst. 

B.  Adhesions  to  the  omentum. — These  are  detached  in  the  same 
■way,  using  hoth  hands  if  necessary.  Catgut  ligatures  are  immedi- 
ately placed  on  the  bleeding  points.  If  some  parts  are  too  adherent 
they  are  seized  with  two  juxtaposed  forceps,  incised  between  them, 
and  ligated  in  small  divisions  with  catgut. 

C.  Adhesions  to  the  intestines.— Hoit  adhesions  are  detached  in 
the  same  manner  as  the  preceding ;  those  of  medium  tenacity  give 
way  to  combined  pressure  and  tension,  acting  alternately  on  the 
cyst  wall  and  on  the  intestinal  wall,  and  always  effected  by  the 
fingers  covered  with  a  compress-sponge.  If  the  intestine  bleeds, 
then  over  a  limited  siu'face  may  be  placed  with  a  fine  needle  one  or 
several  sutures.  If  the  haemorrhage  is  from  a  large  surface, 
persistent  pressure  is  first  tried ;  if  this  is  not  sufficient,  it  may  be 
touched  with  a  strong  carbolic  solution.  If  the  separation  of  the 
intestine  appears  dangerous,  it  will  be  better  to  abandon  detach- 
ment and  proceed  as  I  have  indicated  in  hysterectomy,  by  leaving 
a  thin  layer  of  the  cyst  wall  adherent  to  the  intestine,  disengaging 
it  by  a  minute  dissection.  But  it  is  necessary  to  cauterize  this 
layer  to  destroy  all  the  epithelial  elements  of  the  cyst.  Besides, 
before  commencing  the  detachment  of  intestinal  adhesions  of  any 
extent,  it  is  necessary  to  be  assured  of  their  number  and  of  their 
importance,  and,  if  they  are  too  considerable,  to  confine  one's  self  to 
an  exploratory  incision,  or  to  treat  the  cyst  by  marsupialization 
(which  see  later),  according  to  the  case. 

D.  Pelvic  adhesion. — In  smaU  tumors  the  search  for  adhesions 
should  precede  the  puncture.  In  large  cysts  it  is  necessary  to  first 
diminish  their  volume  to  allow  the  hand  to  glide  into  the  pelvic 
cavity,  at  the  same  time  they  should  be  drawn  outward  with  the 
cyst  forceps.  A  grave  error  that  must  be  avoided,  is  the  mistaking 
a  cyst  fixed  by  extensive  adhesions  for  an  intra-ligamentous  tumor ; 
a  cj'st  of  this  kind  could  be  detached  only  after  having  opened  its 
peritonseal  investment,  as  I  shall  show  later.  Pelvic  adhesions 
must  be  detached  with  the  hand,  and,  if  the  scissors  must  be 
employed,  they  may  be  cut  between  two  forceps  or  two  ligatures.  It 
may  happen  that  the  pelvic  portion  of  the  sac  is  so  adherent  that  it 
cannot  be  extirpated,  a  partial  or  incomplete  operation  will  then  be 
made  according  to  the  technique  to  be  given  later.  It  is  important 
in  small  tumors  not  to  evacuate  the  cyst  before  having  broken  up 
the  adhesions  that  gi\e  way  before  the  hand,  but  incision  should  be 
reserved  until  the  sac  has  been  reduced  by  puncture  in  order  that 
further  manipulations  may  be  guided  by  the  aid  of  the  eye. 

The  evacuation  of  the  cyst  may  be  made  with  the  knife,  but  this 
method  always  exposes  the  wound  to  infection  when  the  jet  of  liquid 


Ovwrian  Cysts.  457 

has  lost  its  force.  The  use  of  the  trocar  seems  preferable.  It  is 
sometimes  necessary  to  puncture  several  cavities  successively.  The 
trocar  should  not  be  withdrawn  in  doing  this.  A  large  trocar  is  of 
advantage  in  the  puncture  of  very  extensive  cysts.  If  the  tumor, 
micro-cystic  or  areolar,  is  not  reduced  by  puncture,  the  abdominal 
incision  is  enlarged  with  the  scissors,  by  dividing  all  the  layers 
with  a  single  cut. 

Third  Stage. — Extraction  of  the  cyst  and  ligature  of  the  pedicle.— 
The  trocar  is  withdrawn  by  a  sudden  movement,  while  the  assistant 
grasps  the  sac  at  the  place  of  puncture  ;  on  this  is  now  placed  the 
cyst  forceps  to  obliterate  it  and  to  facilitate  traction.  A  second 
pair  of  similar  forceps,  or  the  volsella,  is  conveniently  placed  and 
the  delivery  of  the  cyst  is  commenced  by  drawing  gently  with  the 
aid  of  alternate  lateral  movements.  In  proportion  as  the  tumor 
engages,  the  assistant  exerts  pressure  on  the  abdominal  walls  and 
holds  the  lips  of  the  wound  together  so  that  when  the  cyst  is  entirely 
outside,  these  are  closed  on  the  pedicle  and  any  escape  of  the 
intestine  is  avoided.  If  during  the  extraction  there  are  adhesions 
to  be  overcome  that  have  resisted  the  hand,  the  intestinal  bundle 
may  be  pushed  up  by  the  hand  of  the  assistant,  with  the  interpo- 
sition of  a  hot  compress-sponge,  and,  if  necessary,  retractors  may 
be  used  to  open  the  wound  while  the  vascular  adhesions  are  divided 
between  two  ligatures.  The  pedicle  should  now  be  ligated  and 
abandoned  to  the  abdominal  cavity. 

The  principal  disadvantages  of  the  extraperitoneal  treatment  of 
the  pedicle  that  some  authors  use,  are :  mortification,  sometimes 
exposing  to  the  infection  of  the  wound;  the  weakness  of  the 
abdominal  cicatrix  and  the  predisposion  to  hernia.  However,  this 
procedure  is  applicable  in  cases  when  with  cyst  of  the  ovary  there 
is  a  prolapsus  uteri  or  a  pronounced  retroflexion.  It  then  acts  as 
an  hysterorrhaphy. 

It  is  quite  exceptional  to  find  a  pedicle  so  smaU  that  it  may  be 
ligated  by  simply  passing  the  thread  around  it.  It  is  always  much 
more  sure  to  transfix  it  in  the  middle  and  tie  with  a  Tait  or  a 
Bantock  knot.  If  the  width  of  the  pedicle  demands  it,  a  chain 
ligature  may  be  made.  When  the  pedicle  is  short  it  is  better  to 
place  all  the  threads  before  detaching  the  tumor  and  to  incise  the 
pedicle  progressively,  in  small  segments,  that  have  been  tied  in 
advance.  Its  escape  from  the  ligature  will  thus  be  avoided.  If  the 
pedicle  is  very  thick,  very  succulent,  little  differentiated  from  the 
mass  of  the  tumor,  it  is  better  to  use  strong  compression  with 
Billroth's  forceps.  In  a  few  minutes  a  groove  is  thus  obtained  in 
which  the  ligature  win  hold  better  and  in  which  hsemostasis  is 
already  obtained  by  the  crushing  of  the  tissues. 

After  having  detached  the  tumor  the  threads  are  cut  at  one-half 
centimetre  above  the  knot.     Previously,  however,  the  large  vessels 


458  Ovarian  Cysts. 

on  the  surface  of  the  section  are  sought  and  tied  separately  with 
fine  silk  or  catgut.  The  section  is  touched  with  the  strong  carbolic 
solution.  If  the  pedicle  is  exceptionally  fleshy  and  soft,  or 
especially  if  the  sui'face  of  the  section  appears  to  contain  suspicious 
tissue,  cauterization  with  the  actual  cautery  is  used,  carefully  pro- 
tecting the  contiguous  tissues  with  a  moist  compress-sponge.  Some 
authors  ad^-ise  suturing  the  two  Ups  of  the  peritonaeal  wound  above 
the  pedicle,  but  this  appears  useless  as  false  membranes  quickly 
encapsulate  it. 

The  surgeon  then  examines  the  ovary  of  the  opposite  side  and,  if 
it  is  open  to  suspicion,  removes  it,  especially  if  the  woman  is  near 
the  close  of  her  sexual  life.  If  the  woman  is  still  young  and  the 
ovarian  lesion  very  Hmited  the  surgeon  may  confine  liimself  ti) 
excision  of  the  suspected  portion.  The  uterus  should  also  l)e 
carefuUy  examined  and  if  fibrous  nuclei  are  found  they  are  removed 
if  the  woman  be  still  young  and  when  the  operation  appears 
simple.  If  the  woman  be  near  the  menopause  the  removal  of  the 
second  ovary  would  be  preferable. 

Fourth  Stage. — Toilet  of  the  jieritoncEum  and  ocduslon  of  the 
abdomen. — ^When  the  operation  has  been  simple,  without  effusion  of 
irritating  liquid,  it  is  useless  to  stop  to  sponge  the  small  quantity 
which  may  remain  in  the  pelvis;  it  is  easily  absorbed  and  the 
rubbing  of  the  sponges  has  always  the  disadvantage  of  removing 
the  epithelium  and  of  detaching  the  small  clots  wliich  occlude  the 
vascular  openings,  so  that  a  new  oozing  results.  The  surgeon 
proceeds  in  quite  a  diSerent  manner  when  cystic  liquid  or  especially 
pus  has  contaminated  the  operative  field.  In  the  former  case  the 
use  of  the  compress-sponge  is  sufficient.  When  there  has  been  an 
effusion  of  pus,  or  of  very  irritating  cystic  material,  irrigation  of 
the  peritonaeum  is  indicated.  I  have  previously  noted  some  con- 
ditions in  which  dramage  or  tamponnemeut  should  be  made. 

The  surgeon  has  now  only  to  close  the  abdomen  and  for  this  I 
recommend  my  procedure  of  mixed  suture  already  described,  as  it 
avoids  the  hernias  and  eventrations  so  frequently  seen  after  the 
usual  suture  cii  masse. 

I  have  thus  far  described  the  typical  operation,  so  to  speak,  that 
is  practiced  for  pedunculated  cysts.  It  is  now  necessary  to  turn  to 
two  imi)ortant  operative  conditions  that  may  be  present,  one  to  the 
absence  of  a  pedicle,  the  other  the  impossibility  of  constructing  one. 

Enucleation  of  ciz-ita  included  in  thf  broad  ligament  and  retro-peri- 
tonceal. — I  shall  first  dispose  of  the  sub-peritonseal  metastatic 
masses  met  with  either  in  Douglas'  cul-de-sac,  or  in  the  iliac  fossae 
at  the  same  time  with  pedunculated  tumors  of  one  or  both  ovaries. 
To  attack  these  micro-cystic  and  colloid  masses,  infiltrated  more 
than  included  under  the  serous  iiiembrane,  is  to  meet  a  certain 


Ovarian  Cysts.  459 

operative  repulse,  it  is  rarely  possible  to  extricate  them  entirely,  and 
the  enormous  detachments  one  is  obliged  to  make  together  with  the 
remnants  of  neoplasms  left  adherent,  suffice  to  cause  infection. 
The  operation  then  should  be  confined  to  removing  the  peduncu- 
lated ovarian  tumor,  if  this  is  simple,  leaving  the  secondary  masses 
in  place,  or  the  abdomen  may  even  be  closed,  if  the  multiple 
adhesions  which  exist  almost  always  in  such  cases,  are  so  extensive 
that  an  operation  would  be  at  once  laborious  and  incomplete. 

Hyaline  parovarian  cysts. — These  cysts,  with  their  walls  and 
limpid  contents  formed  in  the  thickness  of  the  broad  ligament, 
may  have  made  their  way  under  the  peritonaeum  into  the  meso- 
colon and  the  mesentery.  They  are  very  easily  separated  from  the 
peritoneum,  which  does  not  adhere  to  their  surface,  unless  from 
previous  inflammation.  When  they  are  recognized  a  fold  in  the 
peritonaeum  which  covers  them  should  be  lifted  with  care  and' 
incised.  Introduce  the  finger  into  the  buttonhole  and  detach  the 
serous  membrane  to  a  small  extent ;  on  the  surface  thus  left  free  a 
puncture  is  made  with  the  trocar  and  the  liquid  drawn  ofi'.  The 
trocar  withdrawn,  the  orifice  closed  by  forceps,  the  peritonteum  is 
more  extensively  detached  from  the  surface  of  the  cyst,  the  peri- 
tonseal  incision  enlarged  and  by  persistent  traction,  aided  by  the 
finger  which  breaks  the  cellular  connections,  the  sac  is  totally 
extracted.  Forceps  are  placed  as  required  on  the  bleeding  vessels. 
The  cavity  left  will  become  obliterated  without  interference. 

If  the  sac  has  become  adherent  by  inflammation,  which  often 
follows  an  intra-cystic  apoplexy,  the  evidences  of  which  are  found  in 
the  coloring  of  the  Hquid  and  the  brownish  deposits  in  the  wall,  the 
operation  is  more  difficult.  I  have  twice  found  myself  struggling 
with  a  case  of  this  kind,  and  I  completed  the  operations  only  by 
resorting  to  the  following  procedure,  which  I  recommend  :  Large 
incision  of  the  sac ;  fixing  the  lips  of  the  wound  with  a  crown  of 
forceps,  trusted  to  an  assistant ;  introduction  of  the  left  hand  into 
the  interior  of  the  cyst,  in  such  a  manner  as  to  take  exact  account 
of  its  relations  or  adhesions,  and  to  aid  from  the  inside  the  efforts 
of  a  peeling  off  the  sac  :  the  right  hand  operating  outside  of  the 
cyst  under  the  peritonaeum.  It  is  a  very  important  rule  to  operate 
methodically,  persistently,  not  to  waste  time  in  desultory  efforts. 
Finally,  if  possible,  the  ovary,  generally  healthy,  should  be  spared. 

Pajnllary  cysts  of  the  broad  ligament  and  included  glandular  cysts. — 
I  unite  these  two  kinds  of  cysts  although  they  present  some  ana- 
tomical differences,  because  of  their  great  similarity  in  an  operative 
point  of  view. '  I  have  already  said  that  the  papillary  cysts  of  the 
broad  ligament,  although  proceeding  without  doubt  from  the  par- 
ovarium (either  from  its  intra-ligamentary  portion  or  from  that 
which  penetrates  into  the  hilum  of  the  ovary),  do  not  belong  to  those 


460  Oi-ariaii  Cysts. 

habitually  desiguated  under  the  name  of  parvoarian  cysts.  This 
word  is  most  frequently  applied  to  tlie  most  common  parovarian 
variety  of  hyaline  cysts. 

The  sac  of  papillary  parovarian  cysts  is  thick,  often  suiTOunded 
by  smooth  muscular  fibers  which  seem  to  bind  them  to  the  uterus ; 
the  contents  is  thick  or  milky ;  they  enclose  vegetating  masses,  like 
a  cauliflower.  In  the  thickness  and  vascularity  of  their  walls,  they 
resemble  glandular  or  papillary  cysts  of  the  ovary.  These  cysts 
themselves,  either  because  their  starting  point  is  at  the  border  of 
the  hilum  of  the  organ  (papillary  cysts)  or  because  of  a  semi- 
heterotopic  development,  or  a  congenital  predisposition  (glandular 
cysts),  inay  divide  the  broad  ligament  to  bury  their  base  in  it. 
The  close  and  intimate  relations  with  the  peritonaeum  of  the  uterus, 
the  floor  and  walls  of  the  pelvis,  are  further  points  of  resemblance. 
'The  principal  difference  in  respect  to  anatomical  relations  is  the 
independence  of  the  ovary  in  parovarian  cysts,  and  its  fusion  with 
the  tumor  in  ovarian  cysts.  Of  capital  importance  in  a  purely 
anatomical  point  of  new,  this  difference  is  on  the  contrary  of  little 
importance  in  the  operative  point  of  view. 

For  all  cysts  included  in  the  broad  ligament,  decortication  is 
very  difficult  on  account  of  the  adhesion  of  the  peritonseum,  and 
also  dangerous  because  of  the  close  relation  of  the  base  of  the  sac 
with  the  ureter.  It  is  better  to  empty  the  cyst  at  ouce  than  to 
grasp  it  with  Nelatbn's  cyst  forceps  and  draw  it  outside  the  wound. 
Then  a  large  ellipse  is  marked  with  the  knife  which  includes  all  that 
part  of  the  sac  that  can  be  di-awn  outside  the  abdomen.  The 
incision  comprises  if  possible  only  the  peritonaeum,  and  the  serosa 
is  then  detached  by  using  the  finger,  forceps,  or  spatula,  until  a 
circular  collar  is  left  surrounding  the  sac.  It  is  better  to  commence 
the  decortication  in  the  most  vascular  part  and  ligate  the  large 
vessels  at  once.  For  the  detachment  of  the  uterine  adhesions  this 
organ  must  be  drawn  out  as  far  as  possible.  There  are  some  cases 
in  which  hysterectomy  may  be  performed  to  simplify  the  procedure 
and  to  promptly  terminate  an  operation  that  is  already  too  long. 

Control  of  haemorrhage  may  be  accomplished  either  by  ligature 
or  by  catgut  sutures  superficially  placed  to  avoid  woimding  the 
deep  vessels.  Temporary  compression  with  the  compress-sponges, 
touching,  with  the  thermo-cautery  may  also  be  used  in  persistent 
capDlary  lupmorrhage.  If  these  means  do  not  succeed,  I  should 
prefer  tamponnement  with  idoform  gauze  to  the  practice  of  hanng 
forceps  in  the  abdomen.  The  operation  ended,  the  length  of  the 
intra-abdominal  wound  is  closed  as  far  as  practicable  by  bringing 
the  peritoneal  flaps  together  as  much  as  possible  with  catgut  sutures. 
If  the  carity  is  too  great  to  be  easily  closed  it  must  be  isolated  from 
the  abdominal  earity.  According  to  the  nature  of  the  case,  we 
choose  suture  of  the  borders  of  the  sac  to  the  abdominal  wound. 


Ovariaii  Cysts.  401 

with  tamponnement,  or  the  introduction  of  the  cruciform  drainage 
tube  through  the  posterior  vaginal  cul-de-sac  into  the  bottom  of 
the  sac. 

Incomplete  operation ,-  Marsupialization  of  the  cyst. — When  the 
tenacity  of  the  adhesions  to  the  pelvic  walls  or  to  the  folds  of  the 
broad  ligament  render  impossible,  either  the  formation  of  a  pedicle 
or  enucleation,  one  resource  remains  to  the  surgeon.  This  consists 
in  fixing  the  borders  of  the  sac  to  the  abdominal  wall  and  of  draining 
it  like  an  abscess,  triisting  to  nature  to  obliterate  or  dispose  of  it. 
Before  proceeding  to  fixation  aU  the  superior  portion  of  the 
abdominal  wall  is  closed  above  the  sac  leaving  free  at  its  lower 
angle  only  enough  space  to  accomplish  the  procedure.  The  sac  is 
opened  and  held  by  an  assistant.  One  or  two  large  folds  are  made 
in  the  sac  and  closed  with  a  suture.  Then  a  series  of  strong  sutures 
placed  around  it  passing  through  the  entire  thickness  of  the  sac 
and  that  of  the  alidominal  wall,  at  two  centimetres  from  the  edges 
of  the  wound.  A  second  row  of  superficial  stitches  unites  the  skin 
alone  to  the  sac.  Its  interior  is  carefully  cleansed  and  all  the  vege- 
tations are  removed.  It  is  washed  out  with  sublimate  solution  and 
a  large  drain  placed  in  it. 

An  ovariotomy  in  simple  eases  without  marked  adhesions  should 
be  proceeded  with  as  quickly  as  posible.  The  average  duration, 
including  the  sutures  of  the  walls,  should  not  exceed  twenty  minutes. 
Every  peritonseal  operation  that  lasts  more  than  one  hour  becomes 
dangerous  by  this  fact  alone.  This  danger  will  be  diminished  as 
much  as  possible  by  certain  precautions;  the  assistant  will  always 
hold  the  wound  open  as  little  as  possible;  will  never  leave  the 
intestines  or  omentum  exposed,  covering  them  with  moist  and  hot 
compresses ;  the  operator  wiU  pursue  his  manipulations  outside  the 
abdomen  as  much  as  possible,  constantly  cleansing  liis  hands  by 
plunging  them  into  the  basin  of  sublimate  solution,  1-5000,  placed 
near  him. 

The  dressings  are  as  simple  as  possible.  In  fact,  the  wound  being 
exactly  coapted,  if  the  operation  has  been  aseptic,  there  is  no  need 
for  any  local  dressing,  theoretically  speaking,  and  immobility  and 
compression  are  sufficient.  I  have  had  perfect  reunion  with  a 
simple  cotton  dressing.  However,  it  is  better  to  guard  against 
possible  infection  by  using  antiseptic  dressings.  I  usually  bathe 
the  abdominal  surface  with  sublimate  solution,  powder  the  line  of 
suture  with  iodoform  and  supply  a  compress  of  iodoform  gauze, 
over  this  a  layer  of  absorbent  cotton,  and  finally  a  flannel  bandage 
passing  around  the  body.     Too  nii;ch  pressure  should  not  be  made. 

After-care  ,•  Accidents. — The  patient  should  be  catheterized  every 
three  hours  during  the  first  two  days  at  least,  and  more  if  necessary. 
She  is  placed  in  a  bed  previously  heated,  the  legs  slightly  uplifted 
by  cushion  uuder  the  knees.     If  the  patient  is  very  weak  and  in  a 


462  Ovarian  Cysts. 

state  bordering  on  syncope,  subcutaneous  injections  of  ether  may 
be  given  and  she  may  be  enveloped  in  hot  wi-aps. 

An  internal  haemorrhage  soon  after  the  operation  is  sometimes 
announced  by  a  sudden  sense  of  anguish,  by  exhaustion,  chills, 
cold  sweat,  feebleness  of  the  pulse,  paler  of  the  face.  When" 
drainage  has  been  used,  blood  oozes  from  the  tube.  In  a  case  of 
this  kind  it  may  be  necessary  to  reopen  the  abdomen. 

Duruig  the  first  day  the  patient  should  take  by  the  stomach  only 
bits  of  ice,  a  Uttle  cold  spirits  and  water  or  iced  champagne. 
These  liquids  should  be  administered  in  small  quantity,  as  best 
remedy  for  the  vomiting  is  to  keep  the  stomach  empty.  The  second 
day  a  Uttle  milk  may  be  added.  Some  surgeons  administer  opimi:, 
but  it  is  a  deplorable  practice.  The  third  day,  if  the  vomiting 
continues  or  reappears  Avith  a  porraceous  color,  if  the  abdomen 
becomes  painful  and  swollen,  the  pulse  frequent,  or  even  if  the 
temperature  remains  low,  the  development  of  a  septic  peritonitis  is 
almost  certain.  For  the  diagnosis  of  this  condition  it  should  be 
known  that  the  observation  of  the  pulse  is  of  an  incomparably 
greater  value  than  the  thermometric  record.  Surgical  inflam- 
mations are  even  accompanied  in  some  cases  by  a  true  hypothermia. 
When  the  fatal  issue  arrives,  the  vomiting  becomes  almost 
continuous,  and  the  patient  dies  without  much  suffering,  with  a 
slight  low  delirium. 

One  of  the  best  signs  of  the  beginning  of  the  peritonitis  is  the 
intestinal  paralysis,  which  may  be  recognized  not  only  by  mete- 
orism  but  also  by  non-expulsion  of  flatus.  This  intestinal  paralysis, 
which  is  then  the  result,  may  sometimes  be  a  cause  of  peri- 
toneal inflammation  and  demands  treatment  in  the  beginning. 
The  evening  of  the  second  day,  1  usually  administer  an  enema 
composed  of  sis  spoonfuls  of  a  light  claret  wine  and  thi-ee  of 
glycerine.  If  this  remains  without  efl'ect  on  the  evacuation  of  the 
gas,  I  renew  it  the  following  morning,  adding  one  or  two  spoonfuls 
of  mellitum  mercuriale  and  introduce  into  the  anus  a  gum 
catheter,  No.  20,  which  should  penetrate  to  ten  centimetres  to 
permit  the  exit  of  gas  in  spite  of  the  tonicity  of  the  sphincter.  I 
believe  this  procedure  is  preferable  to  the  administration  per  os  of 
purgatives  that  are  often  vomited.  After  the  fourth  day,  if  all  goes 
well,  the  patient  can  take  solid  food.  On  the  eighth  day  the  silk 
sutures  may  he  removed.  The  dressing  is  then  changed  for  the  first 
time.  The  fifteenth  day  the  patient  may  sit  up  and  take  her  first 
step  a  week  later. 

After  removal  of  sutures  hernial  protrusions  sometimes  develop. 
A  rare  accident  is  emphysema  of  the  abdominal  wall.  Superficial 
abscess  may  form  at  the  level  of  the  suture,  when  antisepsis  has 
been  incomplete  or  where  the  wound  has  been  infected  secondarily 
by  drainage.     Deep  abscess  may  occur  about  the  pedicle  or  buried 


Ovarian  Cysts.  463 

sutures.  Parotitis  has  been  noted  as  a  rare  accident  of  convales- 
cence. A  secondary  peritonitis  may  occur  on  the  tenth  or  fifteenth 
day  and  then  takes  its  origin,  no  doubt,  in  a  septic  condition  of  the 
pedicle,  or  of  other  ligatures  en  masse  which  have  been  left  in  the 
abdomen.  Among  the  rarer  complications  are  intestinal  occlusions. 
Other  exceptional  accidents  are  tetanus,  phebitis,  and  embolism. 

Gravity  of  the  operation. — As  in  all  other  major  operations  it  is 
almost  impossible  to  establish  a  rational  prognosis  for  ovariotomy 
without  distinguishing  between  the  simple  cases  and  the  complicated 
cases.  Unfortunately  this  classification  has  not  been  observed  in 
the  statistics.  However,  according  to  the  most  recent  publications, 
it  seems  that  extirpation  of  a  cyst,  without  extensive  adhesions,  is 
to-day  a  truly  benign  operation.  An  other  considerable  gap  in  the 
majority  of  statistics  is  the  absence  of  sufficient  information  on  the 
causes  of  death.  However,  it  can  be  affirmed  that  the  great  majority 
die  of  septic  peritonitis.  Such  cases  are  almost  always  those  of 
malignant  tumors  with  extensive  adhesions. 

Sequelce  of  the  operation. — ^When  the  tumor  is  of  a  benign  nature, 
recovery  is  complete ;  the  patient  is  predisposed  only  to  hernial 
protrusion  by  relaxation  of  the  cicatrix  if  the  suture  has  not 
been  made  with  the  particular  care  that  I  have  indicated.  A 
cyst  of  the  second  ovary  or  ligament  may  appear.  In  reopening 
the  abdomen  the  siirgeon  should  always  remember  that  the  intestine 
has  a  tendency  to  adhere  to  the  first  cicatrix.  I  have  already 
spoken  of  the  question  of  the  recurrence  of  mahgnant  tumors.  I 
shall  only  recall  the  fact  that  they  generally  remain  localized  in 
the  peritonaBum,  only  exceptionally  invading  the  abdominal  ^^scera 
and  the  wall. 

Menstruation  and  fecmidation  after  op>eration.— Women  operated 
on  one  side  only  continue  to  menstruate  and  are  susceptible  to 
fecundation.  Bilateral  operation  brings  on  a  premature  meno- 
pavise  whenever  the  two  ovaries  have  been  totally  extirpated,  but 
this  may  be  postponed  some  months.  A  very  small  portion  of 
ovarian  tissue  is  sufficient  for  menstruation  and  fecundation. 

Mania  after  operation. — After  ovariotomy,  as  after  any  other 
operation  on  the  female  genital  organs,  cerebral  disturbances  have 
been  observed  in  the  form  of  acute  mania  or  lypemania.  It  is 
especially  among  subjects  presenting  hereditary  antecedents  that 
these  accidents  occur. 

Cysts  complicating  pregnancy. — Ovariotomy  during  pregnancy. — ■ 
Pregnancy  has  been  followed  by  a  normal  delivery  without  the 
intervention  of  the  surgeon,  but  these  are  exceptional  cases.  The 
rule  is  that  small  intra-pelvic  cysts,  even  if  the  pregnancy  is  not 
interrupted,  are  the  cause  of  formidable  accidents  at  the  time  of 
delivery.  The  large  abdominal  cysts  are  an  almost  certain  cause 
of  abortion,  and  are  always  in  danger  of  tortion  of  the  pedicle,  of 


-t(>4  Solid   'Iv)iiors  of  the  Orary. 

rupture  aud  of  suppuration.  The  question  of  tlie  mode  of  inter- 
ference must  be  answered  differently,  according  as  one  is  called 
before  or  during  labor.  Before  labor  I  do  not  believe  there  should 
be  any  hesitation  in  doing  ovariotomy.  The  operation  during  the 
fifth  month  is  infinitely  less  serious  than  later.  During  labor  there 
are  to  be  considered,  in  turn,  the  forceps,  version,  craniotomy  and 
Caesarian  section.  At  first,  attempt  is  made  to  push  the  tumor 
above  the  promontory.  Puncture  aud  incision  of  the  tumor  thi'ough 
the  posterior  cul-de-sac  may  be  thought  of  as  a  means  of  reducing 
the  cyst.  The  forceps  may  cause  rupture;  version  is  rarely 
possible.  There  is  left  the  choice  between  craniotomy,  if  the  child 
is  dead,  and  Csesarian  operation,  if  the  child  is  living.  Caesarian 
and  the  Porro  operations  do  not  appear  to  be  more  fatal  to  the 
mother  than  the  bUnd  ^-iolence  and  the  excessive  force  used  through 
the  natural  passages,  and  they  have  the  advantage  of  saving  the 
child. 


CHAPTER  XXXIII. 


SOLID   TUMORS   OF   THE   OVARY. 

Under  the  term  solid  tumors,  are  usually  comprehended  the 
fibromata,  sarcomata  and  epithehomata  or  carcinomata.  Some 
authors  add  to  these,  papillomata,  enchondromata  aud  tubercular 
growths ;  I  shall  not  imitate  their  example.  In  fact,  I  have  presented 
the  history  of  the  tii-st  with  the  papUlary  cysts  on  which  they 
depend.  Enchondroma  has  no  real  clinical  existence;  it  is  an 
exceedingly  rare  anatomical  lesion  (Kiwisch).  As  to  tubercular 
growths,  they  are  very  exceptionally  locahzed  in  the  ovary,  and 
when  they  give  rise  to  symptoms,  it  is  by  inducing  a  tubercular 
peritonitis,  or  a  pyosalpingitis  where  the  microscope  reveals  the 
giant  cells  and  the  bacilli,  Imt  the  symptomatic  picture  of  which 
confounds  it  with  other  suppurations  of  the  appendages,  of  which 
I  have  spoken  in  the  chapter  on  cystic  oophoro-salpingitis. 

Fibromata. — Pathological  anatomy. — Fibromata  of  the  ovary  are 
rare.  They  do  not  form  limited  neoplasms,  circumscribed,  parasitic, 
almost  independent  of  the  neighlioring  parts,  as  in  fibroids  of  the 
uterus.  There  is  here  a  more  fibrous  degeneration  of  the  organ, 
which  is  uniformly  liypertropliied,  so  that  its  form  and  relations 
are  not  unnatural.  Leopold  has  shown  that  the  tube  presei-ves 
here  all  its  independence  instead  of  becoming  incorporated  with  the 


Solid  Tumors  of  the  Ovary.  465 

ovarian  tumor,  as  in  cysts.  However,  if  the  tumor  has  extensively 
divided  the  broad  hgament  by  being  enclosed  in  it,  this  distinction 
is  lost.  It  may,  then,  be  very  difficult  to  distinguish  a  fibroma 
proceeding  from  the  ovary,  from  a  fibroma  arising  from  the  uterus, 
and  having  acquired  the  same  connections. 

These  tumors  are  generally  small  when  it  is  a  question  of  pure 
fibromata.  It  is  the  fibro-sarcomata  or  the  fibro-mysomata  that 
acquire  such  enormous  dimensions.  Tlie  consistence  of  pure 
fibroids  is  unyielding,  their  surface  is  mammillated  and  they  are 
generally  pedunculated  and  free  from  adhesions,  on  account  of  the 
ascites  they  cause.  An  interesting  variety  of  fibromata,  from  the 
anatomical  point  of  view  only,  is  the  fibroid  of  the  corpus  luteum 
described  by  Eokitansky ;  it  does  not  reach  very  large  dimensions. 
However  Klob  has  seen  one  as  large  as  a  child's  head ;  at  a  glance 
one  recognizes  toward  its  surface  the  denticulated  layer  of  the 
corpus  luteum,  the  structure  of  wliich  is  revealed  by  the  microscope. 

Ovarian  fibroids  usually  contain  small  hollow  spaces  filled  with 
liquid.  Calcification  and  even  ossification  of  these  fibroids  have 
been  found.  The  structure  of  ovarian  fibroids  is  especially  fibrous 
in  the  true  sense  of  the  word.  They  present  an  abundance  of  con- 
nective-tissue fibres  and  little  or  no  non-striated  muscular  fibres. 
When  the  latter  exist  in  abundance  it  is  probable  that  the  origin  of 
the  tumor  has  been  mistaken  and  that  it  proceeds  from  the  utems. 
Exceptionally  the  vessels  may  assume  unusual  dimensions,  as  in 
the  cavernous  fibroids  of  Spiegelberg.  But  these  very  vascular 
tumors  often  contain  a  mixture  of  sarcomatous  tissues.  Fibroids 
of  the  ovary  are  found  relatively  often  in  young  women. 

Symptovu. — It  is  the  ascites  which  generally  attracts  attention 
first.  This  is  induced  by  the  great  mobility  of  the  tumor.  When 
this  symptom  is  lacking,  the  tumor  may  remain  unnoticed,  or  only 
be  discovered  accidentally  during  a  bimanual  examination,  or  during 
a  laparotomy  for  another  condition.  The  progress  is  slow.  Some 
cases  of  peritonitis  have  been  noted. 

Diagnosis. — It  is  almost  impossible  to  distinguish  a  fibroid  of  the 
ovary  from  a  pedunculated  uterine  fibroid.  The  ascites  may  also 
confound  it  with  a  malignant  tumor.  It  is  only  by  exploratory 
incision  that  the  question  can  be  settled. 

The  prognosis  is  favorable  if  the  case  is  one  of  pure  fibroid.  It 
should  be  extirpated  by  laparotomy  as  soon  as  it  gives  rise  to  pain, 
and  even  as  soon  as  it  is  recognized,  for  one  can  never  be  certain 
that  the  tumor  is  not  sarcomatous. 

Sarcoma. — Pathological  anatomy. — This  neoplasm  is  very  rare. 
It  is  most  frequently  bilateral.  The  fibro-plastic  variety  is  more 
common  than  the  encephaloid.  The  first  has  a  lardaceous  con- 
sistency, the  second  is  much  softer.  Cystic  cavities  and  foci  of 
fatty  disintegration   are  frequent  in  the  thickness  of  the  tissue. 


466 


Solid  Tuinorn  of  the  Ovary. 


Numerous  vessels  are  observed.  Their  volume,  geueraUy  moderate, 
may  attain  considerable  proportions.  According  to  Sinety  they 
appear  to  have  been  confounded  with  sarcomata  of  proliferous 
cysts,  in  which  the  solid  element  predominates.  The  description  of 
a  mixed  form,  adenoma  and  carcinoma,  is  perhaps  not  entirely  fi'ee 
from  this  confusion.  Apropos  of  this  there  are  some  researches  that 
are  interesting  by  the  novelty  of  their  results.  There  has  been 
recently  described  a  variety  of  ovarian  neoplasm,  intermediate,  in 
an  histological  point  of  view,  between  epithelioma  and  sarcoma, 
that  has  been  met  repeatedly  in  degenerating  dermoid  cysts,  in 
papillary  cysts  and  in  the  solid  tumors  that  until  now  have  been 
classed  as  sarcomata.  Eckart  and  Pomorsld  have  called  them  en- 
dotheliomata,  to  clearly  indicate  their  origin  from  the  endothelium 
of  the  lymphatic  capillaries  or  spaces,  or  even  from  that  of  the 
capillary  bloodvessels.  They  have  been  able  to  follow,  step  by 
step,  the  transformation  of  the  coimective  tissue  elements  into  epi- 
theloid  cells  in  one  part,  and,  in  the  other,  the  diffuse  proliferation 
(if  the  endothelium  of  the  lymphatic  spaces  of  the  connective  tissue. 
Tliis  neoplasm  is,  then,  mixed  and  participates  both  in  the  char- 
acters of  a  sarcoma  and  an  epithelioma  (Figs.  244  and  '245) 


Fig.  244. — Endothelioma  of  the  ovary  (Pomorski).  A.  Beginning  endothelioma 
in  the  lymphatic  lacunae,  a,  alveolar  dilatation;  p,  proliferation  of  the  cells.  B. 
Reticular  modification  of  the  connective  tissue  under  the  influence  of  endothelial  pro- 
liferation. 1,  lymphatic  lacuna;  b,  interstitial  connective  tissue;  r,  transformation  of 
fibrillar  tissue  into  a  reticular  framework :  e  p,  transformation  of  epithelial  cells  into 
epitheloid  cells. 

The  symptoms  are  those  of  a  malignant  tumor  of  rapid  develop- 
ment. The  surface  is  smooth  and  the  general  form  of  the  ovary  is 
preserved ;  the  lesion  is  sometimes  bilateral.     Ascites  is  constant 


Solid  Tumors  of  the  Ovary. 


467 


and  cachexia  follows   early.      This  rapid   progress   distinguishes 
sarcoma  from  fibroma.    It  is  most  frequently  observed  in  the  young. 
The  only  treatment  is  extirpation.      Recurrence  is  more  to  be 
feared  than  in  fibroid,  but  it  is  less  fatal  than  epithelioma. 


Fig.  245. — Endothelioma  of  the  ovary  (Pomorski).  C.  Stratification  of  the  con- 
nective tissue  in  parallel  layers,  p,  cells  arranged  in  rows;  ff,  fusiform  cells;  e  p, 
direct  transformation  into  epitheloid  cells;  e,  cell  not  completely  transformed;  a, 
beginning  stratification  of  the  connective  tissue.  D.  Alveolus,  e  p,  direct  transfor- 
mation into  epitheloid  cells;  r,  giant  cell ,  i" ,  fusiform  cells;  f,  fusiform  cells  in  the 
wall  of  the  alveolus. 

Epithelioma  or  Carcinoma.  —  If  we  except  secondary 
cancerous  degeneration  of  cysts,  primary  cancer  of  the  ovary  is 
rare.     It  has  been  observed  at  all  ages,  even  in  infancy. 

Pathological  anatomy. — Two  principal  forms  are  described,  the 
diffuse  or  medullai-y,  the  superficial  or  papiUary.  There  is  some 
confusion  on  this  point,  and  papillary  cysts  after  rupture  have  often 
been  described  as  cancerous  papillomata.  This  subject  is  exception- 
ally difficult  because  the  transition  between  these  two  forms  is 
clinically  and  anatomically  imperceptible.  Medullary  carcinoma 
should  also  be  distinguished,  at  least  theoretically,  from  the  pro- 
liferous glandular  cysts  of  colloid  contents  and  small  cavities. 
However,  even  under  the  microscope  the  distinction  is  sometimes 
very  difficult.  In  fact,  we  must  admit,  with  Sinety,  "that  to-day  it 
seems  impossible  to  trace  a  line  of  precise  demarkation  between 
cysts  and  cancers  of  the  ovary." 

The  symptoms  have  nothing  characteristic  in  the  beginning.  But 
soon  the  development  of  ascites  and  general  emaciation,  as  well  as 
the  extraordinarily  rapid  progress  of  the  tumor,  betray  its  malignant 
character. 

As  regards  treatment,  there  are  two  opinions :  one  advising  ex- 
pectation and  palliatives ;  the  other,  operation — if  complete  extir- 
pation be  possible. 


468  Tumors  of  the  Fallopian  Tabes  and  of  th^  Ligaments. 


CHAPTER  XXXIV. 


TUMORS    OF    THE    FALLOPIAN    TUBES   AND   OF 
BROAD   AND   ROUND   LIGAMENTS. 

Tumors  of  the  tubes. — Fibromata  are  rare  and  of  medium 
size.  They  develop  toward  the  exterior  and  do  not,  ordinarily, 
narrow  the  calibre  of  the  oviduct.  Carcinomata  and  sarcomata  of 
the  tube  are  most  frequently  found  as  an  extension  or  metastasis 
from  a  cancer  of  the  uterus.  It  is  quite  remarkable  to  see,  some- 
times, an  advanced  cancer  of  the  ovary  ^\'ith  a  perfectly  normal 
tube.  This  fact  is  due,  without  doubt,  to  the  direction  of  the  flow 
(if  the  lymph  (Olshausen).  It  appears,  from  the  published  cases, 
that  cancer  of  the  tube  develops  most  frequently  near  the  menopause 
and  that  its  progress  is  slow.  It  gives  rise,  early  in  its  development, 
to  a  sanious  leucorrhoea  that  is  in  contrast  with  the  healthy  condition 
of  the  uterus. 

A.  Doran  has  described  a  papilloma  of  the  tubes  that  he  compares 
with  condylomata  of  the  vulva  and  vagina.  He  believes  that  these 
productions  are  not  neoplasms  but  simple  hj'perplasias  due  to  a 
chi'onie  intlammation  of  the  organ. 

Tumors  of  the  broad  ligaments. — The  cysts  have  been 
studied  mth  those  of  the  ovary,  with  which  they  belong,  cHnically. 
Fibroids  independent  of  the  uterus  have  been  found  in  the  broad 
ligament.  Are  they  primaidly  developed  from  the  coimective  and 
the  muscular  tissues  proper  to  these  folds,  or,  are  they  due  to  the 
migi-ation  of  iiterine  fibroids?  It  is  impossible  to  solve  this 
problem.  Tedenat  has  observed  an  enormous  fibro-cystic  tumor 
accompanied  with  other  purely  fibrous  tumors  of  the  broad  liga- 
ment. The  supernumerary  ovaries  which  may  exist  above  the 
normal  ovary  should  not  be  taken  for  small  fibroids.  Lipomata 
have  been  seen  very  rarely  in  the  broad  ligament.  Epitheliomata 
and  sarcomata  are  only  the  result  of  extension  from  contiguous 
organs.     Parovarian  varicocele  has  been  noted  by  Eichet. 

Echinococfi  induce  a  chronic  inflammation  -with  aai  induration  of 
the  coimective  tissue. 

The  local  symptoms  may  be  nil,  aside  from  the  phenomena  of 
compression,  and  the  general  health  is  not  altered.  The  tumors  are 
rounded,  elastic,  seated  by  preference  in  the  vicinity  of  the  rectum 
in  the  posterior  portion  of  the  pelvis,  slightly  mobile,  not  painful. 
Bimanual  palpation  shows  that  they  are  not  closely  connected 
with  the  uterus  or  the  ovaries.     Exploratory  puncture  is  dangerous. 


Tumors  of  the  Fallopian  Ttibes  and  of  the  Ligaments.         469 

Diagnosis  can  scarcely  be  made  except  by  exclusion  and  by  relative 
frequency  of  the  echinococci  in  some  countries. 

The  treatment  will  vary  with  the  situation  of  the  tumor.  If  it  is 
large,  and  projects  into  the  abdomen,  laparatomy  will  permit  either 
complete  enucleation  or  evacuation  and  drainage. 

Tumors  of  the  round  ligaments. — Cysts  or  hydroceles. — An 
accumulation  of  serum  may  be  observed  encysted  in  the  interior  of 
the  inguinal  canal  or  at  its  external  orifice.  It  is  quite  natural  to 
attribute  this  lesion  to  the  persistence  of  the  canal  of  Nuck.  But 
this  origin,  though  admitted  by  many,  is  denied  by  Duplay.  How- 
ever, Schroeder  affirms  that  in  a  case  he  observed  the  fluid  could  be 
pushed  up  into  the  abdomen.  The  cyst  may  sometimes  be  found 
in  the  interior  of  the  round  ligament.  The  gubernaculum  of  Hunter, 
which  later  becomes  the  round  ligament,  is  primarily  hollow, 
according  to  Weber,  and  there  may  be  persistence  of  a  foetal 
state  favoring  the  production  of  a  pathological  condition.  I  will 
return  to  this  subject  apropos  of  the  glands  of  Bartholin. 

Fibromata  may  be  present,  either  purely  fibrous  or  as  fibro- 
myomata,  fibro-sarcomata,  or  fibro-myxomata.  Calcareous  degene- 
ration has  been  noted,  also  a  lymphangiectasic  myoma  of  the  round 
ligament. 

The  right  side  is  most  fi'equently  affected,  and  the  tumors  are 
almost  always  found  in  parous  women.  The  tumor  may  be  situated 
at  the  internal  orifice,  intra-peritonseal,  or  externally  in  the  labia 
majora  or  toward  the  inguinal  fold.  Independent  of  the  integument, 
often  pedunculated,  sometimes  sessile,  the  tumor  is  smooth  or 
slightly  lobulated,  generally  of  a  fibrous  consistency.  Insensitive 
to  pressure,  it  causes  pain  by  compression  when  it  attains  a  con- 
siderable size.  Cough  and  straining  do  not  affect  fibroids.  It  is 
only  in  the  beginning,  when  these  tumors  are  very  small,  that  they 
can  sometimes  be  reduced  in  part  into  the  inguinal  canal.  They 
have  been  known  to  increase  in  size  during  pregnancy  and  even 
during  each  menstrual  period.  The  progi-ess,  while  slow  in  pure 
fibroids,  may,  in  mixed  tumor,  have  the  rapidity  of  malignant 
gi'owths. 

In  a  prognostic  point  of  view  we  must  distinguish  cases  in  which 
there  exist  a  pedicle  from  those  in  which  there  is  none.  If  there  be 
a  pedicle  and  it  passes  below  the  crural  arch,  the  tumor  is  not  one 
of  the  round  ligament.  If  it  passes  above,  the  tumor  may  belong 
to  the  ligament  or  may  be  a  fatty  hernia,  an  epiplocele,  or  a  hernia 
of  the  ovary.  The  differential  diagnosis  may  be  established  by  the 
following :  Fatty  hernia  often  diminishes  on  pressure,  is  painful 
to  touch  and  during  its  growth.  Its  consistence  is  soft,  its  limits 
iU-defined.  Irreducible  epiplocele,  which  sometimes  acquires  a 
fibrous  consistence  quite  comparable  to  that  of  fibroid,  will  be 
impossible  to  distinguish  without  the  history  and  the  presence  of 


470  Genital  Tuberculosis. 

an  epiploic  cord  behind  the  abdominal  wall.  The  ovary  in  hernia 
is  ovoid,  having  the  regular  form  of  the  organ  and  has  an  exquisite 
sensitiveness  to  pressure.  The  increase  in  size  in  menstruation  is 
still  more  marked  than  that  seen  in  some  fibroids.  The  uterus  is 
in  latere -version. 

If  there  be  no  pedicle  and  the  tumor  is  developed  toward  the 
groin,  it  might  be  taken  for  a  ganglionic  mass.  But  in  that  case 
the  tumor  is  always  multiploid  and  offers  no  special  connections 
^vith  the  inguinal  orifice.  If  the  tumor  is  situated  in  one  side  of 
the  vulva  it  may  be  confounded  \^ith  a  cyst  of  a  Bartholinian  gland. 
Its  origin  -nill  be  sought  for  both  by  the  history  and  by  direct 
examination. 

The  prognosis  wDl  be  indicated  by  its  progress.  The  treatment 
is  extii-pation. 


CHAPTER  XXXV. 


GENITAL   TUBERCULOSIS. 

Invasion  of  the  genital  apparatus  by  tubercular,  bacilli  is  rare. 
Some  regions,  the  vagina  and  the  cervix  for  example,  appear  very 
refi'actory,  -svithout  doubt  on  account  of  the  resistence  of  the  strati- 
fied pavement  epithelium  which  protects  them.  The  tubes  are 
most  often  the  point  of  origin  of  the  tubercular  lesions.  From  the 
tubes  the  disease  is  easily  propagated  to  the  ovaries  and,  more 
rarely,  to  the  uterus. 

I  shall  present  as  a  whole  the  picture  of  tuberculosis  of  the  genital 
organs  by  adopting  the  anatomical  order. 

TJiaiorical  sketch.— The  principal  works  marking  the  first  steps  in 
our  knowledge  of  this  subject  are  those  of  Louis,  Senn,  Raymond, 
and  Cruvilhier.  With  Aran,  Bernutz,  and  Brouardel  especially, 
pathological  anatomy,  although  still  compelled  to  accord  a  pre- 
ponderating importance  to  the  microscopic  appearance,  assumes 
greater  precision,  and  the  clinical  description  is  already  improved 
(1858  to  1865).  Since  then  the  discovery  of  the  tiibercular  follicle 
and  that  of  Koch's  bacillus,  has  given  us  a  criterion  to  guide  our 
reseai'ches,  at  the  same  time  that  improving  surgical  skill  permitted 
the  study  of  fresh  preparations.  The  names  of  Hegar,  "Wiedow, 
Cornil  and  Terrillon  are  connected  with  the  latest  works  on  patho- 
logical anatomy  and  treatment. 

In  a  pathogenetic  point  of  view  we  may  cite :     Conheim,  who 


Genital  Tuberculosis.  471 

"was  the  first  to  advance  the  idea  of  a  possible  transmission  by 
sexual  relations ;  Vernenil,  who  has  vigorously  defended  this  view, 
and  has  demonstrated  the  utility  of  comparing  the  inoculated 
woman  with  the  inoculator,  the  method  that  has  given  so  great 
progress  in  the  etiology  of  syphilitic  accidents ;  Verchere,  Fernet 
and  DerviUe,  who  have  reported  very  probable  facts  of  genital  con- 
tagion; Eeclus,  who  has  discussed  them. 

Etiology;  Pathogeny. — Is  th.re  a  primary  tuberculosis  ?  This 
fact  is  beyond  doubt.  Geil  and  Tomlinson,  in  working  out  the  facts 
already  indicated  by  Namias,  Cristoforis  and  Eokitansky,*  have 
long  since  cited  numerous  examples  of  isolated  tuberculosis  of  the 
appendages.  It  is  proper  to  state,  however,  that  the  observations 
preceding  the  specific  determination  of  the  tubercular  follicle  and 
of  the  characteristic  baciUus,  do  not  have  a  decided  importance. 
But  the  most  recent  verifications  have  plainly  confirmed  this  fact. 

Primary  tuberculosis  of  the  male  genital  organs  is  also  common. 
One  of  the  most  ciirious  features  of  tliis  variety  of  local  tuberculosis 
in  both  sexes  is  the  possibility  of  remaining  a  long  time,  or  even 
indefinitely,  latent  or  unrecognized,  in  consequence  of  its  perfect 
isolation  by  false  membranes  and  by  the  inspissation  of  pus.  This 
is  especially  observed  in  the  tubes,  and  it  may  then  be  impossible 
to  find  the  bacilli,  as  they  are,  without  doubt,  destroyed  in  time, 
although  the  tubercular  nature  of  the  focus  may  be  clearly  demon- 
strated by  the  appearance  of  an  acute  miliary  tuberculosis,  either 
pulmonary  or  meningeal.  This  history  of  old  tubercular  foci  in  the 
bones  or  articulations  furnishes  numerous  analogous  examples. 

How  is  the  tubercular  bacillus  carried  to  the  female  genital 
organs '?  Their  easy  communication  with  the  exterior,  seems,  a 
priori,  to  permit  frequent  infection,  either  by  the  atmosphere,  by 
the  introduction  of  infectious  bodies,  or  by  the  ingestion  of  tubercu- 
lar spermatic  fluid. 

This  theory  could  be  admitted  only  after  the  works  of  Villemin 
and  Koch  had  overthrown  the  accepted  ideas  on  the  origin  of 
tuberculosis.  Even  to-day  tliis  theory  of  direct  infection  is  not 
accepted  without  protest.  It  appears  to  have  both,  defenders,  who 
are  so  enthuziastic  that  they  are  disposed  to  accept  numerous 
observations  that  are  without  sufficient  proof,  and,  systematic 
detractors.  In  fact,  this  mode  of  infection  appears  very  probable, 
although  it  certainly  is  the  exception. 

The  frequency  of  this  primary  tuberculosis  in  comparison  with 
secondary  infection  has  been  studied.  Mosler  has  found  eight 
primary  cases  out  of   forty-six  observations.     Frerichs  gives  the 

*Rokitansky,  Lehruch  der  pathol.  anat.,BA.l\l,-p.  444,  1844;  Lenhart  (/"Wraa?-,? 
Tuberciilose  der  Ttiben  bei  einer  by-jahrigen  Fran.)  has  cited  a  case  of  primary 
tuberculosis  of  the  uterus  with  obliteration  of  the  uterine  orifice;  Derville  (DeTinfection 
tuberculeuie par  la  voir  genitals  chez  la  femme)  has  reported  numerous  observations  of 
primary  tuberculosis,  but  some  of  them  appear  doubtful. 


472  Genital  Tnherculosis. 

proportion  fifteen  out  of  ninety-six,  and  Scbi-amm  only  one  out  of 
thirty-four. 

With  regard  to  the  agents  of  infection  in  primary  tuberculosis, 
it  is  easy  to  account  for  them  if  the  patient  has  been  in  contact 
with  those  affected  with  this  disease ;  the  hnen,  a  sound,  the  finger 
of  a  surgeon  or  mid^\ife  may  carry  the  germ.  Cohabitation  vdih.  a 
man  affected  with  genital  or  pulmonary  tuberculosis  appears  to  be 
the  recognized  cause  in  numerous  instances.  Is  it,  then,  fi-om  the 
spermatic  fluid,  fi-om  the  saliva,  or  fi-om  the  blood  of  an  excoriation, 
that  the  inoculation  occurs  ? 

The  puerperal  state  plays  an  incontestable  part  in  the  primary 
affection.  This  fact  has  been  noted  by  all  authors.  The  genital 
passage  is,  in  fact,  very  open  then  to  the  entrance  of  all  morbid 
germs,  and  the  obstetrical  manipulations  may  contribute  to  theii" 
introduction.  It  is  also  necessary  to  note  that  an  infection  of  any 
nature  whatever,  septicaemic  or  blennorrhagic,  predisposes  to 
tubercular  infection.  We  know  how  the  puerperal  state  predisposes 
to  the  fii"st ;  these  may,  then,  so  to  speak,  open  the  road  for  the 
second.  These  facts  are  well  known  in  general  pathology  under 
the  term  of  mixed  or  combined  infection. 

Secondary  tuberculosis,  that  is  to  say,  developed  in  the  course  of 
a  tubercular  degeneration  of  another  organ,  and  of  the  Imigs  iu 
particular,  is  observed  incomparably  more  often  than  the  primai'y 
disease.  Before  affirming  that  we  have  only  the  latter,  it  is  neces- 
sary to  ascertain  that  there  does  not  exist  the  least  tubercular 
nodule  in  the  apex  of  the  lung,  and  the  difficulties  of  such  a 
diagnosis  are  well  known. 

This  is  truly  the  defective  point  in  many  of  the  so-called  demon- 
strative observations  that   have  been  published.     Another  weak 
point  has  been  a  too-ready  admission  of  the  tubercular  nature  of 
the  small  induration  of  the  epididymis  or  prostate  found  in  the 
presumed  soui'ces  of  the  infection. 

The  tuberculosis  of  the  genital  organs  which  follows  in  the  course 
of  phthisis  comprises  two  varieties,  in  a  pathological  point  of  view. 
In  the  majority  of  these  cases,  %\ithout  doubt  the  genital  tubercu- 
losis is  a  secondary  metastasis,  in  the  opinion  of  Conheim,  the 
microbe  has  emigrated  with  the  blood  or  the  lymph  from  the  primary 
to  the  secondary  focus.  But  at  other  times  there  is  infection  by 
a  different  mechanism  approaching  to  that  of  primary  infection 
of  non-tubercular  individuals.  The  patient  then  mfects  her  geni- 
tals through  an  external  medium,  which  she  herself  has  first 
infected.  It  is  without  doubt  by  the  soiled  linen,  the  diarrho&ic 
stools,  or  the  sputa,  that  the  vagina  is  inoculated,  in  advanced 
tuberculosis,  with  ulcerations  of  that  organ. 

Finally,  tubercular  inoculation  extends  from  place  to  place  by 
contact  or  by  propagation,  by  way  of  the  lymphatics,  in  cases  where 


Genital  Tuherculosis.  473 

there  exists  intestinal  tuberculosis  which  has  attacked  the  pelvic 
ganglia.  The  bacilli  of  the  peritonaeum  may  also  infect  the  paTilion 
of  the  tube.  Pinner  has  shown  that  dust  introduced  into  the  peri- 
tonfeum  is  rapidly  carried  into  the  tube  and  from  there  into  the 
iiterus.  The  same  should  be  true  of  germs,  and,  in  fact,  Janes, 
ill  a  case  of  pulmonary  and  intestinal  phthisis  has  found  numerous 
bacilli  in  the  section  of  tubes  still  perfectly  normal.  Without  doubt 
they  come  from  the  peritonfeum,  into  which  they  had  migrated 
from  the  intestine.  Infection  of  the  tube  also  occurs  by  adhesion  of 
a  loop  of  tubercular  intestine,  in  the  same  way  that  a  recto-vaginal 
tubercular  fistula  may  succeed  to  a  perforation  of  the  septum,  in 
cases  of  ulceration  of  the  large  intestine. 

The  predilection  of  tubercular  lesions  for  the  tubes  is  explained 
by  several  considerations :  Their  mucosa,  very  rich  in  folds,  not 
subject  to  menstrual  changes  as  that  of  the  uterus,  is  admirably 
adapted  to  the  retention  of  morbid  germs  that  have  been  able  to 
reach  it.  The  great  vitality  of  the  uterine  mucosa,  its  partial 
desquamation  at  each  menstrual  period,  is,  without  doubt,  its  prin- 
cipal defence  against  the  baciUi.  With  regard  to  the  vagina,  it  is 
protected  by  a  thick,  stratified  layer  of  its  epithelium,  and  perhaps 
by  the  vital  concurrence  of  the  numerous  germs  to  which  it  always 
offers  shelter.  We  cannot,  according  to  Vernenial,  establish  a 
comparison  between  the  conditions  of  proliferations  of  the  bacilli, 
wluch  is  anaerobic  and  develops  by  preference  at  a  gi'eat  depth,  and 
those  of  other  microbes  which,  like  the  gonococcus,  attack  the  first 
portion  of  the  genital  canal  that  they  meet. 

Tuberculosis  of  the  vulva,  of  the  vagina  and  of  the 
cervix. — Tubercular  ulceration  of  the  vulva  is  quite  an  excep- 
tional lesion.  M.  Zweigbaum,  who  has  described  an  example,  has 
only  found  two  cases  reported.  His  patient,  aged  tlnrty-two  years, 
was  phtliisical  and  succumbed  to  intestinal  and  pulmonary  tubercu- 
losis. The  author  believes,  however,  that  the  genital  lesion  was 
primary.  There  were  also  ulcerations  on  the  vagina  and  cervix 
uteri.  BaciUi  were  found  in  abundance  in  a  small  section  excised 
during  life  from  the  M.ilvar  ulceration. 

Cases  of  tuberculous  lesions  of  the  vagina  or  the  vaginal  portion 
of  the  cer^dx  are  rare.  Daurias,  however,  has  collected  twenty- 
four,  but  it  should  be  noted  that  they  are  not  all  beyond  criticism. 
The  external  appearance,  and  certain  presumptions  drawn  from 
various  chcumstances,  are  not  sufficient  to  characterize  such  a 
lesion.  However,  there  exist  a  number  of  incontestable  facts.  We 
can  only  mention  miliary  tubercules  that  are  met  in  acute  tubercu- 
losis. It  is  also  necessary  (to  distinguish  in  a  special  article)  the 
primary  or  secondary  tuberculization  of  certain  tracts  that  connect 
the  vagina  with  the  neighboring  organs. 

I  have  only  found  a  single  case  of  isolated  primary  ulceration  of 


474 


Genital  J'uherculosis. 


the  vagina,  one  observed  by  Max  Bierfreund.  Usually  this  lesion 
coexists  with  primary  alterations  of  the  tubes  or  of  the  uterus.  In 
a  remarkable  case,  by  Yii'chow,  there  was  tuberculosis  of  the  urinary 
passages  and  infection  of  the  vagina  from  the  urine.  The  rectum 
may  also  be  the  point  of  depai-tm-e. 


Fig.  246. — Tuberculosis  of  the  uterus,  of  the  vagina,  and  of  the  tubes  (Barnes) ;  a 
h,  tubercular  masses  of  the  mucosa  and  of  the  uterine  tissue :  /,  ulcerations  of  the 
vagina;  c,  tubes  transformed  into  pyosalpinx. 


<.-         C  '  ^  :2; 


Fig.  247.— Bacilli  of  tuberculosis.     A.  Phthisical  sputum.    B    Pure  culture  of 
Koch's  bacillus. 

Tubercular  ulceration  of  the  vagina  presents  perpendicular, 
miequal  and  aufractuose  edges,  and  a  depressed,  yellowish-gi-ay 
base,  covered  with  a  caseous  layer  that  is  quite  characteristic. 
Around  the  iilcer  fi'equently  exist  yellow,  opaque  gi-anules,  similar 
to  those  which  surroiind  the  lingual  tubercular  ulceration,  so  well 
described  by  Trelat.  Koch's  bacillus,  found  at  the  surface  of  these 
ulcerations  or  in  the  vaginal  secretions,  leaves  no  doubt  of  the 


Genital  Tuberculosis. 


475 


nature  of  the  disease,  when  it  can  be  demonstrated,  which  is  not 
always  the  case. 

These  tubercular  ulcerations  can  be  cured,  temporarily,  by  simple 
means,  such  as  painting  \Adth  tincture  of  iodine,  or  with  lactic  acid, 
but  recurrence  is  rapid;  for  with  a  superficial  alteration  of  the 
cervix,  there  is  found  an  invasion  of  the  muscular  layer  by  tubercu- 
lar folheles. 


■■%■  ¥i*--^^  g-  m^mm 


Fig.  248. — Tuberculosis  of  the  cervix.  Section  of  the  mucosa  of  the  cervical  cavity 
(30  diameters);  m,  mucus;  /,  folds  and  villi  covered  by  cylindrical  epithelium;  gff^, 
glands \  aaa,  giant  cells  (Cornil). 

Tubercular  fistulas  of  the  vagina,  according  to  Daui-ios,  may  be 
vesico  urethro  or  recto-vaginal.  They  have  no  character  that 
clearly  distinguishes  them  from  ordinary  fistulfe  occupying  the 
same  regions.  The  presence  of  the  bacilli  or  of  the  tubercular 
follicles  around  their  orifice  alone  permits  recognition  of  their  special 
nature. 

Observations  of  tubercules  limited  to  the  cervix  uteri  are  very 
few.  However,  one  case  is  reported  by  A.  Laboulbene.  Another 
has  been  described  at  length  by  Cornil ;  it  deserves  mention  as  a 


476  Genital  Tuberculosis. 

remarkable  type  of  this  rare  lesion.  I  shall  borrow  its  description. 
The  case  was  one  in  which  Pean  performed  total  hysterectomy. 
The  clinical  diagnosis  of  the  lesion  was  doubtful.  The  aspect  of  the 
hypertropied  cervix,  indurated,  rough,  with  irregular  vegetations, 
bathed  in  a  thick,  yellowish,  clotted,  mucous  Uquid,  caused  fear  of 
cancer,  and  on  this  hypothesis  Pean  removed  the  uterus.  "  Opening 
of  the  cervical  cavity  showed  the  cervical  folds  marked,  vegetating, 
agglutiuated  by  a  tenacious  mucus  and  stre^^•n  with  opaque  bodies. 
Histological  examination  revealed  tuberculosis  of  the  cervix,  hmited 
to  this  part  of  the  uterus."  This  case  is  extremely  iuteresting 
on  account  of  its  rarity,  and  the  limitation  of  the  tubercular 
processes.  The  preparations  obtamed  after  hardening  in  alcohol, 
by  cutting  sections  pei-pendicular  to  the  surface  of  the  mucosa, 
show,  with  a  low  power  (Fig.  248),  the  cervical  folds  presenting 
secondary  viUi,  and  separated  by  depressions  into  which  open  the 
utricular  or  composite  glands  of  the  cer^•ix.  The  surface  of  the 
mucosa  as  well  as  the  depressions  and  the  glandular  cavities  were 
filled  with  mucus.  The  glandular  cavities  were  enlarged  and  at 
the  same  time  the  connective  tissue  was  filled  with  small  cells.  In 
this  connective  tissue,  at  the  surface  of  the  mucosa,  even  at  the 
summit  of  the  folds,  in  the  superficial  layers  as  well  as  in  the 
depths  between  the  glands,  giant  cells  w'ere  distinguished  large 
enough  to  be  seen  under  a  low  power.  The  surface  of  the  mucosa, 
the  basis  of  its  folds  and  ^Tlli,  as  well  as  the  canities  of  the  glands, 
are  lined  with  long  cylindi-ical  cells.  With  a  higher  power  there  is 
seen  (Figs.  249  and  250)  between  the  glands,  in  the  connective 
tissue  of  the  mucosa,  an  infiltration  of  numerous  small  cells,  of 
giant  cells  wholly  characteristic,  which  appear  to  constitute  in  them- 
selves alone  all  the  tiibercular  lesion.  It  is  true  that  the  connective 
tissue  which  surrounds  them  is  richer  in  round  cells  than  iu  the 
normal  state,  but  they  belong  rather  to  a  physiological  condition. 
Besides,  most  fi-equently,  around  the  giant  cells  there  do  not  exist 
agglomerations  of  epitheloid  cells  nor  an  accumulation  of  cells  in 
granular  or  necrotic  degeneration.  Thus  it  is  that  the  tubercular 
foUicles  iu  this  case  were  never  visible  to  the  naked  eye. 

The  tuberciUar  productions  developed  on  the  surface  of  the 
mucosa,  covering  the  exterior  of  the  cervix ;  that  is  to  say,  in  its 
vaginal  portion,  presented,  iu  this  preparation,  the  same  appearance 
as  the  tubercles  of  the  pharyngeal  mucosa.  Giant  cells  are  seen  in 
the  midst  of  an  accumulation  of  small  cells.  These  granulations 
are  covered,  at  their  beginning  and  for  a  long  time,  by  the  normal 
layers  of  stratified  pavement  epithehum.  Under  the  mucosa  are 
found  tubercular  follicles  in  small  number,  situated  in  the  midst  of 
interlacing  muscular  fasciculi.  These  muscular  fasciculi  are,  at  a 
given  point,  separated  by  embryonal  connective  tissue  forming  an 
islet,  in  the  centre  of  which  there  is  one  or  several  giant  cells 


Genital  Tuberculosis. 


477 


surrounded  by  epitheloid  cells.     These  tubercular  granulations  are 
more  voluminous  than  those  of  the  surface  of  the  mucosa.     They 


Fig.  249. — Same  section  as  in  the  preceding  figure  (100  diameters);  m,  mucus;  s, 
villi  and  papilli ;  g,  glands ;  v,  vessels  ;  cc  c,  giant  cells ;  /,  a  papilla  with  i  c  in- 
flamed connective  tissue. 

present  there  an  arrangement  quite  analogous  to  that  observed  in 
the  muscular  layers  of  the  intestine  or  in  the  lingual  muscle ;  that 
is  to  say,  they  are  developed  in  the  interfascicular  connective  tissue 


478 


Genital  Tuberculosis. 


pushing  back  by  their  extension  the  muscular  filjers  at  their 
periphery.  It  is  necessary,  then,  to  expect,  even  when  it  is  beUeved 
that  there  is  a  shght  superficial  tubercular  emption  of  recent  date, 
never  having  produced  ulceration,  nor  loss  of  substance,  that  the 
deep  tissue  of  the  mucosa  and  even  the  muscular  layer  may  lie 
invaded  by  some  tubercular  granulations.  These,  in  small  number 
it  is  true,  follow  the  course  of  the  vessels  in  the  intermuscular  con- 
nective tissue  spaces. 


Fig.  250. — Tuberculosis  of  the  cervix  uteri.  Same  section  still  more  enlarged  (150 
diameters) ;/,  papillae  and  vegetations;  /,  connective  tissue;  ?,  fissure  showing  epi- 
theloid  cells  belonging  to  a  tubercular  follicle;  ir,  giant  cell ;  h,  gland;  ?«,  mucus;  6, 
epithelial  cells  of  the  gland;  v,  vessels  (Cornil). 

"When,  even  in  tuberculosis  of  recent  date,  histological  exami- 
nation reveals  such  an  extension  of  the  disease  in  depth,  we  cau 
draw  the  conclusion  that  it  is  not  sufficient  to  attack  the  disease  by 
superficial  measures  nor  by  curetting,  and  that  total  ablation  wiM 
often  be  the  only  means  of  removing  all  the  tubercular  portions  of 
the  uterus. 

Cornil  sought  in  vain,  in  this  characteristic  case,  for  the  baeilH 
of  tuberculosis,  but  inoculation  of  animals  from  it  produced  tubercu- 
losis. 

Winter,  on  the  contrary,  found  baciUi  in  the  giant  cells  of  a  section 
of  mucosa  from  the  body  of  the  uterus  and  of  others  from  the 
cervix.  The  ease  was  one  of  a  tuberculous  young  woman  on  whom 
Schi-oeder,  five  years  and  a  half  before,  had  made  a  laparotomy, 


Genital  Tuberculosis.  479 

followed  by  the  introduction  of  iodoform  into  the  abdomen  for  a 
tubercular  peritonitis,  with  such  success  that  the  health  was  marvel- 
ously  re-established.  But,  after  a  long  respite,  the  tuberculosis 
became  manifest  in  the  lungs  and  in  the  genital  apparatus.  The 
tubes  were  attacked  as  well  as  the  uterus. 

Tubercular  lesions  induce  about  themselves  and  in  all  the  mucosa 
a  very  marked  degree  of  cervical  endometritis.  The  inflammatory 
disturbances  act  both  on  the  epithelial  lining  of  the  surface  and  of 
the  glands  and  on  the  chorion. 

In  comparing  the  preceding  description  with  that  of  the  beginning 
of  tuberculosis  of  the  tube,  that  I  shaU  give  later,  according  to 
Cornil,  it  will  be  seen  that  between  the  lesions  of  the  cervical 
cavity  and  those  of  the  tubal  mucosa  there  is  a  striking  analogy. 
There  is  the  same  situation  of  the  giant  cells  at  the  summit  of  the 
folds  and  villi,  or  in  the  connective  tissue  of  these  folds.  There  are 
the  same  inflammatory  phenomena,  the  same  mucous  secretions, 
and  the  same  modifications  of  the  epithelial  cells. 

It  is  quite  possible  that  the  tubercular  inoculation  may  be  made 
without  an  erosion  or  a  solution  of  continuity  of  the  cer\Tical  mucosa, 
by  simple  contact.  That  this  takes  place  in  animals,  has  been 
demonstrated  by  Cornil  and  Dobroklowsky.  But  these  facts  can  be 
applied  to  the  human  race  only  with  the  greatest  reserve. 

The  diagnosis  of  tubercular  ulcerations  of  the  vulva,  of  the  vagina, 
or  of  the  cervix,  can  be  made  with  some  chance  of  certainty  only  in 
cases  where  these  lesions  coexist  with  advanced  pulmonary  lesions. 
The  discovery  of  tubercular  follicles,  and  especially  of  the  bacilli,  in 
a  fragment  obtained  by  scraping  or  by  excision,  will  alone  be 
pathognomonic.  In  cases  of  primary  genital  lesions,  there  is  great 
risk  of  confusion  with  some  more  frequent  lesion. 

The  treatment  should  be  palliative,  if  it  relates  to  advanced 
phthisical  subjects;  energetic  in  the  opposite  case.  Cauterization 
with  the  actual  cautery  and  iodoform  dressings  for  vaginal 
ulcerations  are  used.  Fistulous  tracts  are  to  be  freely  excised.  If 
the  diagnosis  is  certain  there  should  be  no  hesitation  in  performing 
hysterectomy  even  for  a  circumscribed  ulcer  of  the  cervix. 

Tuberculosis  of  the  uterus. — Pathological  anatomy. — In  the 
uterus  tuberculosis  is  almost  always  secondary.  Tln-ee  forms  have 
been  indicated  somewhat  theoretically : 

1.  A  rare,  acute  miliary  form,  which  offers  no  interest  in  a  clinical 
point  of  view,  and  which  is  only  an  epiphenomenon  in  the  course  of 
a  general  infection  of  the  economy  with  predominance  of  the  general 
symptoms. 

2.  An  interstitial  form,  of  slow  progress,  essentially  chronic, 
equally  rai'e,  impossible  of  diagnosis,  but  which  may  suddenly 
become  manifest  by  a  grave  accident,  such  as  uterine  rupture, 
obstacle  to  delivery,  etc.,  resulting  from  the  alteration  of  the  uterine 


480 


Genital   Tidierculosis. 


tissue  and  from  the  obstruction  to  the  ])hysi()logical  action  of  this 
organ  by  the  interstitial  tubercles. 

3.  An  ulcerous  form,  which  is  the  most  frequent  and  the  most 
important.  In  this  last  form  the  lesions,  from  the  begimiing, 
resemble  only  those  of  endometritis,  to  which  are  added  special 
nodules  and  giant  cells  containing  bacilli.  Later,  the  tubercular 
follicles  become  confluent,  all  the  mucosa  is  iiiiiltrated  by  a  tissue 
formed  of  small  cells.  It  presents,  then,  a  total  caseous  degeneration. 
It  is  yellowish  and  opaque  to  a  depth  of  one  to  two  millimetres. 
Underneath,  the  musci;lar  tunic  is  often  hj'pertrophied.  Neither 
at  the  surface  of  the  mucosa,  nor  on  section,  can  the  naked  eye 
distinguish  tubercular  granules  resembling  the  classical  description 
of  miliary  tuberculosis  of  the  serous  membranes.  The  cavity  of  the 
uterus  is  sometimes  filled  by  a  thick  magma.  It  may  be  trans- 
formed into  a  pocket  of  pus  by  the  occlusion  of  the  cer^^x. 


Fig.  251. — Tuberculosis  of  the  uterus  and  tubes  (Barnes). 

The  lesion  is  usually  limited  above  the  superior  portion  of  the 
cervix,  which  remains  intact.  The  limit  may  be  marked  by  an 
ulceration  with  a  border  of  as  sharply- defined  edges  as  if  cut  with 
a  punch.  According  to  Cornil,  the  structural  changes  revealed  by 
microscopical  examination  are  as  follows  : 


Genital  Tuberculosis.  481 

"  Sections  perpendicular  to  the  surface  of  the  corporal  mucosa, 
made  after  hardening  in  alcohol,  show  no  vestige  of  its  normal 
structure,  no  epithelium,  no  glands,  no  recognizable  vessels.  All 
the  caseous  portion  of  the  surface  presents  to  the  microscope  an 
homogeneous  layer  formed  of  small  necrosed  vitreous  cells,  no 
longer  stained,  with  nuclei  tinted  in  rose  color  by  the  picro-carmine. 
The  cells  are  separated  by  fine  fibrillfe  interlacing  in  every  du-ection. 
Above  the  necrosed  layer,  there  is  a  zone  showing  small  living  cells, 
and  between  them,  here  and  there,  some  giant  cells.  Then,  coming 
to  the  muscular  wall,  there  are  also  seen  some  tubercular  follicles. 
In  sections,  comprising  all  the  wall,  with  the  peritonasum,  there  are, 
internally,  the  caseous  infiltration  replacing  the  mucosa,  some 
tubercular  foUicles  in  the  muscular  wall,  and  granulations  situated 
in  the  peritonfeum.  Cornil  sought  in  vain  for  the  tubercular  bacilli 
in  a  dozen  sections  of  the  degenerated  mucosa." 

The  caseous  infiltration,  accompanied  by  superficial  necrosis,  the 
detached  products  of  which  constitute  the  caseous,  curdy  pus  that 
fills  the  uterine  cavity,  is  the  most  characteristic  type  of  this 
chronic  tuberculosis.  Cornil  compares  tliis  lesion  to  that  of  the 
same  nature  often  found  in  the  renal  pelvis,  the  calices  and  the 
ureters.  "  This  similarity  is  obvious.  It  consists,  in  the  body  of 
the  uterus  as  in  the  urinary  passages,  of  a  yellowish-white  opaque 
thickening,  with  induration  of  the  mucosa,  which  is  wholly  necrosed. 
The  surface  of  this  is  inlaid  with  a  molecular  fragmentation  with 
particles  mixed  with  pus,  giving  it  a  grumous  appearance.  The 
microscope  gives  quite  the  same  appearance.  The  caseous  surface 
presents  an  homogeneous  aspect,  a  uniform  infiltration  with  cells, 
without  distinct  tubercular  islets. 

"  It  is  with  difficulty  in  the  deep  layer  still  living,  that  giant  cells 
can  be  recognized  here  and  there.  From  this  it  results  that  we  can 
say  of  the  pathological  anatomy  of  tuberculization  of  the  tube^  and 
uterus,  that  there  is  not  usually  found,  whether  in  the  chi-onic  state 
or  the  recent,  tubercular  granulations  perceptible  to  the  naked  eye 
or  to  the  microscope,  that  correspond  to  the  classic  descriptions  of 
tubercles.  In  fact,  granulation^  of  the  serous  membranes  have 
been  taken  as  the  type,  and  this  type  is  only  rarely  met  in  the 
genital  mucosa." 

The  rarity  of  bacilli  in  uterine  tuberculosis  is  not  astonishing. 
It  is  certain  that  they  exist,  but,  as  in  the  majority  of  local  tubercu- 
loses (tuberculosis  of  the  testicle,  lupus,  etc.),  they  are  in  very 
small  number,  probably  because  of  the  long  existence  of  the  lesion. 
E.  Doyen  has  recently  found  them  in  an  autopsy  on  a  young  woman 
who  died  of  typhoid  fever.  She  also  presented  tubercles  of  the 
uterine  mucosa  and  muscular  tissue. 

The  symptoms,  in  the  beginning,  are  those  of  an  ordinary  me- 
tritis with  a  more  pronounced  enlargement.     Thus,  this  affection, 


482  Genital  TuLtrculosts. 

which  is  perhaps  more  frequent  than  is  supposed,  may  pass 
um-eeoguized.  The  caseous  nature  of  the  secretions  and  the  coex- 
istence of  lesions  of  the  tubes  and  of  the  lungs  call  for  search  for 
the  granulations  and  the  bacilli  which  are  alone  characteristic. 
However,  the  histological  diagnosis  presents  gi-eat  difficulties.  It 
is  not  necessary  to  wait  until  there  are  found  in  the  uterine  mucosa 
the  tubercular  folhcles  that  are  met  with  in  the  serous  membranes. 
It  may  be  that  the  elementary  granulation  of  Virchow  will  be  the 
only  constant  lesion,  and  this  is  difficult  to  differentiate  from  a 
stroma  akeady  so  rich  in  identical  elements.  Finally,  the  giant 
cell,  which  may  be  met  with,  according  to  some  authors,  in 
interstitial  endometritis,  cannot  clearlj'  estabUsh  the  diagnosis. 
However,  according  to  Paul  Petit,  we  can  determine  the  tubercular 
nature  of  an  endometritis  with  an  almost  absolute  certainty,  if  the 
examination  of  the  debris  furnished  by  curetting  reveals  the  foUowing 
characters :  Interstitial  cells,  necrosed  or  atrophied,  in  a  diffuse 
manner,  or  in  series ;  giant  cells,  more  or  less  numerous ;  embry- 
onal nodules,  detached  from  the  stroma  and  appearing  developed 
around  the  vessels ;  numerous  glands,  dilated,  lined  by  epitheHal 
elements  considerably  elongated,  or  that  have  undergone  epithehal 
elements.  To  this  end  an  exploratory  curetting  should  be  made  to 
avoid  confusion  with  cancer  of  the  body  of  the  uterus. 

Treatment — If  the  state  of  the  lungs  permits  a  radical  treatment, 
vaginal  hysterectomy  should  be  done  instead  of  waiting  for  results 
of  the  curette.  If  the  utenis  is  too  large  and  the  tubes  are  sus- 
pected, there  should  be  no  hesitation  in  removing  these  organs  by 
laparotomy.  If  the  cervix  be  intact,  supravaginal  hysterectomy 
may  be  done ,  if  it  be  affected,  total  hysterectomy  must  be  per- 
formed. 

Ovaries  and  Tubes. — Pathological  Anatomy. — The  ovary  is 
rarely  attacked  alone.  Some  cases  have  been  cited  by  Klob  and 
Spencer  WeUs.  Lesions  of  the  tubes  are,  on  the  contraiy,  more 
frequent.  Terrillon  has  seen  these  lesions  exist  simultaneously  in 
the  tube  and  in  the  ovary  thi-ee  times  out  of  six. 

In  the  majority  of  cases  of  tubal  lesions,  tubercular  endometritis 
is  observed,  and  is  then,  without  doubt,  the  primary  source  of 
infection.  With  the  naked  eye  there  are  obsei-ved  lesions  which 
recall  those  of  suppui-ative  salpingitis,  \vith  or  without  dilatation. 
The  pyosalpinx  may  be  considerable,  and  even  have  a  capacity 
of  two  litres.  Adhesion  and  diffusion  toward  the  contiguous  parts 
transfonn  it  into  a  pehic  abscess  {Fig.  252).  Though  the  lesion 
may  be  recent  it  early  reacts  on  the  peritonaeum  and  develops  false 
membranes  and  the  encysted  serous  effusions  of  perimetro-salpin- 
gitis.  Fernet  has  even  noted  progi'essive  invasion  of  the  plem-se  and 
the  production  of  subacute  peritoneo-pleural  tuberculosis  arising 
from  a  primary  lesion  of  the  genital  organs.     This  invasion  occm-s 


Genital  Tiiherculosis. 


483 


byway  of  the  lymphatics,  that  Hegar  has  seenmjected  with  caseous 
material.  The  lymphatic  communication  of  the  pleura  with  the 
peritonaeum  through  the  diaphragm  explains  this  infection.  The 
mesenteric  glands  are  often  degenerated. 


Fig.  252. — Primary  tuberculosis  of  the  tubes  and  ovaries ;  U,  uterus ;  O  d,  right 
ovary;  T,  tubes  dilated  and  adherent  to  a  tubercular  pel  vie*  abscess  limited  by  the 
ilium  (Kotschan). 

Tuberculosis  of  the  tube,  developed  primarily  or  consecutiye  to 
the  appearance  of  granulations  in  the  contiguous  peritonaeum,  is 
recognized  with  the  naked  eye  by  the  increase  in  the  size  of  the 
organ,  by  the  semi-transparent  or  yellow  granulations  which  exist 
on  its  surface  or  m  the  muscular  wall,  and  by  its  contents.  After 
opening  the  tube  longitudinally,  we  recognize  that  it  is  dilated,  that 
the  thick  wall  contains  tubercular  islets  often  visible  to  the  naked 
eye,  and  that  it  is  filled  with  a  more  or  less  thick,  puriform, 
grumous,  caseous  fluid,  characters  like  those  of  tuberculosis  of  the 
body  of  the  uterus  (Fig.  253). 

Transverse  sections  obtained  after  hardening  in  alcohol  show  a 
thickening  of  the  wall  and  of  hypertrophied,  ramifying  vegetations. 
In  the  depth  and  at  the  internal  surface  of  these  vegetations  and 
villosities,  there  are  often  found  giant  cells  with  multiple  ovoid 
nuclei,  and  sometimes  crystalline  concretions  (Fig.  254).  The  free 
surface  of  the  folds  and  villi  is  almost  always  covered  with  ciliated 
cylindrical  cells.  In  places  these  epithelial  cells  are  modified  by 
mucous  and  granular  transformation,  or  they  are  desquamated  and 
free  m  the  mucus  with  some  globules  of  pus.  Staining  the  sections 
in  the  search  for  baciUi  does  not  always  reveal  them.  Besides  the 
giant  cells  and  the  small  tubercular  follicles  developed  in  the 
vegetations,  larger  follicles  containing  giant  cells  are  found  in  the 
fibro-muscular  wall.  In  the  case  of  alterations  of  longer  standing 
there  is  seen,  in  sections  of  the  purulent  sac  formed  by  the  tube,  a 
layer  of  embryona  tissue  at  the  inner  surface.  Under  this  internal 
layer  there  is  a  fibrous  tissue  strewn  with  quite  clear  tubercular 


484 


Genital  2'uherculosis. 


follicles,  many  of  which  contain  multinuclear  giant  cells.  The  wall 
of  the  tube  is  infiltrated  with  small  cells  and  also  presents  some 
tubercular  follicles.     In  the  laj'er  of  fibrous  tissue  between  the 


&1 


Fig.  253. — Tuberculosis  of  the  tubes.  Section  of  the  wall  of  a  pyosalpinx  {150 
diameters);  M,  muscular  layer;  Co gl,  glandular  layer;  Cg,  giant  cells;  Nt,  tuber- 
cularnodules;  A,  arteriole;   Gr,  internal  layer  of  granulations  (Munster  and  Ortman). 

wall  and  the  embryonal  layer,  there  are  seen  inclusions  of  epithe- 
lium, proceeding  from  the  epithelial  cells  of  the  mucous  coat.  These 
iufoldings  present  the  form  of  tubular  glands.  At  their  periphery 
are  observed  cylindrical  cells  regularly  disposed  in  rows.  In  the 
central  part  of  the  inclusion  there  exist  rounded  or  ovoid  ceUs,  pale, 
staining  yellow  by  picro-carmine,  but  without  -sisible  nuclei.  This 
is  a  mass  of  necrotic  cells  becoming  mucoid,  agglutinated  to  one 
another  (Cornil).  This  lesion  has  been  called  necrosis  by  coagu- 
lation. Koch's  bacilH  have  been  sought  in  vain  in  some  eases  of 
salpingitis  that  are  certainly  tubercular.  They  have  been  found, 
however,  though  in  small  quantity,  by  Orthmanu,  Werth,  and  others. 


Genital  Tuberculosis.  485 

The  symptoms  are  the  same  as  those  of  a  non-tubercular  salpin- 
gitis, and  one  must  be  content  in  most  cases  with  a  probable  diagnosis 
by  the  exclusion  of  all  other  causes,  by  taking  into  account  the 
hereditary  antecedents  and  the  manifestations  which  may  exist  in 
the  lungs.  The  nodular  character  of  the  tumor  and  the  frequency 
of  acute  attacks  of  iDelvi-peritonitis  have  been  given  as  characteristic. 
But  they  are  not  specially  characteristic,  as  they  are  met  with  in 
all  the  varieties  of  pyosalpinx. 


Fig.  254. — Giant  cells  in  genital  tuberculosis  (340  diameters). 

As  to  treatment,  it  is  necessary  to  distinguish  two  distinct  con- 
ditions, according  as  there  exists  a  pulmonary  tuberculosis  or  not. 
If  the  lungs  are  healthy,  complete  extu-pation  of  both  tubes  and 
both  ovaries  is  attempted  by  laparotomy.  If  the  woman  is  phthisi- 
cal, we  are  limited  to  palliatives.  Among  these  may  be  mentioned, 
the  opening  of  the  tuberculous  focus  tkrough  the  abdomen,  or 
through  the  vagina,  and  careful  disinfection  by  the  aid  of  tam- 
ponnement  with  iodoform  gauze. 

If  the  pulmonary  lesions  are  of  little  intensity,  the  surgeon  should 
be  guided  by  considerations  analogous  to  those  which  would  guide 
him  in  the  treatment  of  any  other  focus  of  local  tuberculosis. 

Hegar  counsels  interference  in  primary  tuberculosis  as  soon  as 
the  diagnosis  has  been  made.  In  secondary  tuberculosis  inter- 
ference is  necessary  if,  the  condition  of  the  lungs  remaining 
stationary,  the  genital  lesion  has  a  tendency  to  advance.  PeritonsBal 
tuberculosis  is  not  a  contraindication.  Laparotomy  has  been  very 
successful  in  such  cases. 


486  Pelvic  TLematocele. 


CHAPTER  XXXVI. 


INTRA-   AND   EXTRA-PERITONEAL   PELVIC 
H-ffiMATOCELE. 

Definition;  Division. — The  etfusiou  of  Ijlood,  iutra-pelvie  litemor- 
rliage,  should  not  be  confounded  with  hsematocele.  This  word, 
wliich  has  both  an  anatomical  and  a  clinical  significance,  should  be 
reserved  for  encysted  sanguineous  collections.  A  similar  character 
is  taken  only  by  sanguineous  effusion  in  special  pathogenetic  con- 
ditions that  give  to  the  lesion  a  permanence,  making  it  a  distinct 
morbid  entity.  The  effused  blood  may  have  either  of  two  different 
situations :  1.  In  the  interior  of  the  peritonieum  and  then  generally 
beliind  the  uterus.  This  is  intra-peritonaeal  hsematocele,  the  clinical 
history  of  wliich  has  been  clearly  traced.  2.  The  blood  is  effused 
below  the  peritonaeum,  in  the  broad  ligaments  and  in  the  perivaginal 
cellular  tissue.  It  forms  there  a  veritable  thrombus  and  was  so 
called  by  the  older  writers.  The  term  extra-pei'itonseal  haematocele 
is  certainly  less  exact  than  that  of  hematoma,  but  it  has  been 
perpetuated  by  usage. 

Intra-peritonseal  pelvic  hsematocele. — .■Etiology,  Patho- 
gcny. — Effusion  of  blood  into  the  pelvic  cavity  is  probably  quite 
frequent.  It  is  hardly  to  be  doubted  that  the  tube,  at  the  menstrual 
period,  may  be  the  seat  of  a  sanguineous  exudation  analagous  to 
that  of  the  uterus.  Many  of  the  troubles  observed  at  this  period, 
under  the  disturbing  influence  of  fatigue,  muscular  strain,  or  a  chill, 
are  certainly  caused  by  the  effusion  of  a  small  quantity  of  blood 
into  the  peritonseal  cavity,  from  which  it  is  quickly  absorbed.  But 
if  the  serosa  is  altered  or  destroyed  its  power  of  resorption  quickly 
disappears.  If  effusion  then  takes  place,  the  gi-eat  quantity  of 
blood  is  taken  up  by  resorption  so  slowly  that  the  clots  which  form 
play  the  role  of  a  foreign  body.  Then  the  altered  peritonseum, 
aroused  to  its  ordinarj*  means  of  defence,  isolates  this  cause  of 
irritation  by  the  formation  of  false  membranes.  The  blood  thus 
imprisoned  in  this  adventitious  pocket  undergoes  a  slow  molecular 
disintegration,  or  in  some  eases  under  septic  influences  it  becomes 
mixed  with  pus. 

When  the  blood  of  an  intra-peritouiPal  salpingorrhagia  is  effused 
slowly  and  in  a  relatively  small  quantity,  a  pre-existing  lesion  is 
necessary  to  oppose  its  resorption,  and  this  pre-existing  lesion  is  the 
inflammation  of  the  pelvic  serosa  around  the  diseased  tubes.  The 
inflamnuition  of  the  tube  prepares  in  advance  for  encysting  the  blood 


Pelvic  Hcematocele.  487 

by  producing  false  membranes  around  the  pavilion,  a  proof  of  which 
is  found  in  the  remains  of  the  septa  of  the  sac.  Slight  attacks  of 
pelvic  peritonitis  have  been  noted  in  the  beginning  of  almost  all 
cases. 

The  usual  origin  of  extensive  sanguineous  effusions  is,  without 
doubt,  the  rupture  of  a  tubal  pregnancy.  I  shall  return  to  this 
apropos  of  extra-uterine  pregnancy. 

The  pathogenetic  question  has  been  and  still  remains  sharply 
contested. 

I  shall  pass  in  review  the  theories  wMch  have  been  successively 
advanced.  It  is  quite  probable  that  each  one  corresponds  to  a 
certain  series  of  facts,  but  that  a  single  factor  is  constant,  that  is, 
the  impermeability  of  the  pelvic  peritonieum,  primary  or  secondary, 
either  in  consequence  of  a  previous  peritubal  inflammation,  or 
because  of  the  abundance  of  the  effusion  itself.  The  rupture  of 
varices  of  the  utero-ovarian  venous  plexus  has  been  especially 
insisted  upon  by  Eichet.  Winckel  has  demonstrated  that  the  phle- 
bolites  contained  in  these  varicose  veins  may  cause  ulceration  of 
their  walls.  The  theory  which  refers  the  production  of  the  hsema- 
tocele  to  a  disturbance  in  ovulation,  assumes  that  the  tube  is  not 
exactly  applied  on  the  ovary  at  the  proper  time,  allowing  effusion 
of  blood  into  the  peritonaeum .  The  majority  of  the  older  authors 
denied  that  the  tube  itself  takes  part  in  the  catamenial  haemorrhage 
but  admit  the  possibility  of  a  reflux  of  blood  from ,  the  uterus. 
Guerin  advanced  the  idea  that  menstrual  disturbance  produced  by 
membranous  dysmenorrhcea  is  of  a  nature  that  may  cause  effusion 
of  blood  into  the  peritonseal  cavity.  Micro-cystic  degeneration  and 
cysts  of  the  corpus  luteum  are  sometimes  the  seat  of  apoplexy 
which  by  rupture  may  cause  an  intra-peritonfeal  htematocele.  The 
theory  of  pachyperitonitis  has  certainly  been  abused.  To  an 
effusion  of  blood  from  the  rupture  of  an  extra-uterine  pregnancy, 
Huguier  has  given  the  name  of  pseudo  hsematocele.  But  if  this 
effusion  be  circumscribed  and  encysted,  why  should  we  refuse  to 
call  it  hematocele  ?  In  addition  to  these  pathegenetic  factors  it 
should  be  stated  that  any  general  disease  which  causes  haemorrhage 
may  produce  an  effusion  of  blood  into  the  peritonseum. 

Pathological  anatomy. — The  tumor  is  ordinarily  situated  in  Douglas' 
cul-de-sac.  However,  this  cul-de-sac  may  have  been  obliterated  by 
a  previous  plastic  inflammation,  then  the  blood  may  collect  between 
the  uterus  and  the  bladder.  At  the  outset  the  blood  is  liquid  ^nd 
forms  a  pool  which  may  be  displaced,  for  it  is  rare  that  pre-existing 
false  membranes  form  a  sac  at  once.  Encystment  quickly  occurs 
and  then  the  blood  is  separated  from  all  parts  of  the  intestinal  mass. 
In  consequence  of  this  it  may  be  very  difficult  to  distinguish 
the  neomembranous  structure  from  the  peritonaeum,  and  to 
differentiate  an  intra-peritonaeal  from  an  extra-peritonseal  haema- 


488 


Pelvic  HcBmatocele. 


tocele.  In  the  last  case,  however,  the  tumor  is  more  lateral,  for 
it  is  especially  the  folds  of  the  broad  ligament  which  have  been  sep- 
arrted. 

The  sac  adheres  in  front  to  the  posterior  surface  of  the  uterus 
which  is  pushed  toward  the  symphysis.  It  has  a  blackish  color. 
The  ovaries  and  the  tubes  are  more  or  less  um-eeognizable  and 
blended  with  the  walls  of  the  tumor.  Sometimes  the  tubes  are 
filled  ^\ith  blood  and  ruptured.  Only  one  presents  these  lesions  if 
the  condition  is  due  to  a  foetal  cyst.  The  agglutinated  intestines 
may  adhere  to  the  sac.  When  it  is  opened  a  large  cavity  is  found 
in  which  the  blood  is  coagulated  or  semi-liquid,  syrupy,  according 
to  the  age  of  the  lesion.  The  color  is  dark,  resembhng  that  of  a 
raisin.  At  the  external  portion  there  are  sometimes  found  layers 
of  fibrin  ah-eady  decolorized  and  whitish.  The  walls  of  the  sac  are 
thick  in  some  points,  very  thin  in  others,  when  a  rupture  appears 
imminent.     The  rectum  is  flattened  and  displaced  (Fig.  255). 


Fig.  255. — Retro-uterine  hjematocele.     U,  uterus;  R,  rectum; 
A,  intraperitoneal  hasmatocele. 

The  volume  of  the  tumor  varies.  It  may  attain  that  of  a  uterus 
at  term.  If  it  persist  long,  obstruction  of  the  ureters  from  pressure 
may  cause  renal  lesions  as  in  other  tumors  of  the  abdomen.  Sup- 
puration has  often  been  observed.  At  other  times  there  is  found 
at  the  autopsy  evidences  of  an  attempt  at  spontaneous  cure, 
resorption  of  the  liquid,  and  retraction  of  the  sac,  fiUed  with  a  new 
gro^vtla  of  connective  tissue  colored  with  blood  pigment.  Even  in 
cases  where  there  is  a  suspicion  of  the  rupture  of  a  tubal  pregnancy 
as  the  origin  of  the  lesion  vestiges  of  the  fcetus  are  hardly  ever  found. 


Pelvic  Hcematocele. 


489 


But  even  if  the  foetus  leaves  no  traces  an  attentive  examination 
will  discover  the  remains  of  the  chorion  that  frequently  demonstrate 
the  origin  of  the  lesion. 


Fig.  256. — Retro-uterine  haematocele.     U,  uterus;   B,  bladder; 
H,  liKmatocele. 

Symptoms.— The  appearance  of  an  hematocele  is  almost  always 
preceded  by  morbid  symptoms,  pertaining  to  the  uterine  appendages, 
pain,  menstrual  disturbances,  and  gastric  reflexes.  They  are  the 
signs  of  the  salpingitis  or  of  the  extrauterine  pregnancy.  It  is  rare 
that  the  effusion  is  not  marked  by  acute  symptoms,  but  their 
intensity  is  quite  variable.  They  may  be  fulminant,  and  according 
to  Barnes'  expression,  cataclysmic,  lipothymia,  syncope,  chills, 
threatening  death.  If  the  patient  survives  this  internal  hsemorrhage, 
the  symptoms  of  the  abdominal  tumor  are  pronounced  while  the 
general  symptoms  subside  by  degrees.  In  less  severe  cases,  the 
beginning  is  marked  simply  by  local  pain  and  a  sense  of  weakness, 
associated  with  an  increase  in  the  size  of  the  abdomen.  Finally,  a 
sanguineous,  intra-peritonseal  oozing  may  occur  in  an  almost 
insensible  manner,  insidiously. 

In  the  days  which  foUow  the  first  appearance  of  the  morbid 
symptoms,  a  plastic  peritonitis  circumscribes  the  effusion  and 
causes  nausea,  tympanitis,  pain  and  fever. 

The  objective  signs  revealed  by  bimanual  exploration  are  those  of 
a  fluctuating  tumor,  occupying  Douglas'  cul-de-sac,  pushing  the 
uterus  forward  so  that  the  cervix  is  not  easily  reached.  If  it  can 
be  reached  it  is  found  flattened  against  the  pubes.  The  tumor  does 
not  long  remain    fluctuating.      It   soon  acquires   a  consistence 


490  Pelvic  Hematocele. 

resembling  that  of  snow.  This  consistence  varies  much;  in  some 
parts  it  is  found  very  hard,  in  other  very  soft.  Bimanual  explo- 
ration reveals  the  uterus  in  the  center  of  the  tumor  (Fig.  256). 
Eectal  examination  is  difficult  from  the  obliteration  of  the  gut. 
This  pressure  may  give  rise  to  symptoms  of  internal  strangulation ; 
that  of  the  bladder,  to  retention  of  urine ;  that  of  the  sacral  plexus, 
to  acute  neuralgia  in  the  lower  limbs. 

The  general  condition  is  variable ;  even  in  the  absence  of  suppu- 
ration the  fever  is  frequently  observed  in  irregular  paroxysms  and 
is  caused  by  the  peritonaeal  reaction  during  the  formation  of  false 
membranes.  The  progress  is  essentiaUy  chronic,  but  exacerbations 
are  frequently  observed,  as  if  new  effusions  took  place.  These 
fresh  attacks  occur,  sometimes  a  few  days  after  the  accident,  some- 
times later  at  the  menstrual  period.  In  cases  where  the  hemor- 
rhage arise  fi-om  the  rupture  of  a  foetal  cyst,  the  return  of  the 
accident  is  particularly  to  be  feared  and  may  cause  death  speedily, 
even  when  all  danger  appears  to  have  passed.  Outside  of  excep- 
tionally grave  cases,  the  disease  has  a  natural  tendency  to  recovery 
by  progressive  resorption  or  by  spontaneous  evacuation.  But  the 
latter  mode  of  cure,  which  only  occurs  by  suppvu-ation,  gives  rise  to 
grave  symptoms. 

In  fortunate  cases  the  patient  remains  for  some  months,  incapable 
of  walking  and  exposed  to  relapses.  It  may,  after  its  disappearance, 
leave  an  indurated  nodule,  or,  simply,  a  uterine  misplacement  with 
immobility  of  this  organ. 

Suppurative  inflammation  is  announced  by  the  general  appearance 
of  the  patient,  and  by  the  onset  of  erratic  chills  and  sweat.  At 
the  same  time  the  tumor  increases  in  size  and  its  induration 
diminishes.  Perforation  into  the  abdominal  cavity  is  very  rare. 
The  peritonitis  which  follows  the  suppm'ation  is  rather  due  to  the 
direct  extension  of  the  inflammation.  Perforation  of  the  rectum  is 
more  frequent.  Preceded  by  the  symptoms  of  proctitis,  it  is  marked 
by  the  sudden  appearance  of  a  blackish  and  fetid  diarrhcea  which 
causes  an  immense  relief  and  the  disappearance  of  the  tumor. 
This  evacuation  may  lead  to  complete  cure.  But,  in  other  eases, 
death  may  occur  from  marasmus  from  septic  infection.  Perforation 
into  the  vagina  is  rare ;  perforation  into  the  bladder  is  quite 
exceptional. 

Diagnosis. — The  clinical  picture  of  hjematocele  is  often  so  charac- 
teristic that  it  does  not  admit  of  doubt.  The  sudden  appearance 
of  a  retro-uterine  tumor,  coincident  mth  the  symptoms  of  an 
internal  htemorrhage,  is  truly  pathognomonic.  The  ruptm-e  of  a 
pyosalpinx  or  of  a  pelvic  abscess  gives  place  only  to  acute  pain,  to 
signs  of  peritona;al  reaction,  generally  much  more  intense,  and  not 
to  the  tumor  which  appears  in  the  beginning  of  the  hiematocele. 
There  should  be  no  confusion  with  a  retroflexed  gi-avid  uterus. 


Pelvic  Hcsmatocele.  491 

One  of  the  best  means  of  avoiding  this  error  is  to  examine  carefully 
for  the  outlines  of  the  uterus,  which  in  haematocele  wiU  be  found  in 
the  center  of  the  tumefaction.  This  examination  will  be  much 
facilitated  by  anesthesia.  Cysts  of  the  ovary  and  uterine  fibroids 
wedged  in  the  pelvic  cavity  have  nothing  in  common  with  hsemato- 
cele,  and  the  same  is  true  of  extra-uterine  pregnancy.  At  a  late 
period  the  residual  inflammatory  products  of  perimetro-salpingitis 
can  be  distinguished  only  by  the  history. 

Prognosis. — This  affection  is  serious ;  it  may,  in  rare  cases,  cause 
sudden  death ;  the  patient  is  exposed  to  grave  accidents  until  re- 
covery is  complete.  Finally,  resolution  is  scarcely  ever  perfect. 
The  plastic  residues  situated  around  the  uterus  are  a  frequent  cause 
of  ill-health  and  almost  certainly  cause  sterility. 

Treatment. — Only  active  interference  is  legitimate  when  symptoms 
appear  that  compromise  the  patient's  life.  If  in  the  beginning  the 
symptoms  are  moderate  ice  may  be  applied  over  the  lower  portion 
of  the  abdomen  to  combat  both  the  hfemorrhage  and  the  peritonitis. 
The  patient  should  be  kept  absolutely  at  rest,  the  bladder  being 
regularly  emptied  by  eatheterism,  the  rectum  by  enemas.  The  use 
of  opium  to  calm  the  pain  should  be  guarded.  Particular  care 
should  be  taken  with  the  antisepsis  of  the  vagina  to  avoid  infection 
through  the  genital  canal. 

As  soon  as  the  patients'  life  is  in  danger,  either  from  pressure 
effects  or  by  those  of  inflammation,  there  should  be  no  hesitation 
in  evacuating  the  sac.  Incision  is  preferable  to  puncture.  The 
location  of  the  incision  is  determined  by  the  protrusion  of  the 
tumor. 

If  it  projects  markedly  in  the  posterior  cul-de-sac  it  should  be 
attacked  through  the  vagina.  The  cervix  is  drawn  forward,  the 
index  finger  of  the  left  hand  is  placed  in  the  rectum,  the  labia  are 
separated  as  much  as  possible  by  means  of  retractors,  and  an  in- 
cision is  made  in  the  direction  of  the  long  axis  of  the  tumor,  taking 
care  not  to  go  too  far  laterally  to  avoid  wounding  the  ureters.  The 
finger  in  the  rectiim  serves  as  a  guide  against  injuring  the  rectum. 
Immediately  on  reaching  the  cavity  of  the  tumor  the  incision  is 
enlarged  as  requhed  with  the  scissors  and  a  weak  antiseptic  in- 
jection is  used  to  coax  out  the  clots  and  the  sirupy  material.  Care 
should  be  taken  not  to  destroy  the  limiting  adhesions.  A  loose, 
tamponnement  of  the  cavity  of  the  sac  is  made  with  strips  of  iodo- 
form gauze,  wliich  is  left  in  place  forty-eight  hours.  On  removing 
these  tampons,  the  antiseptic  irrigation  is  repeated  and  then  a 
cruciform  drainage-tube  is  placed  in  the  sac  with  iodoform  gauze 
lightly  packed  around  it.  The  free  extremity  of  the  tube  will  be 
encased  in  an  antiseptic  dressing.  It  will  also  serve  for  injections 
into  the  sac,  once  or  twice  a  day,  if  necessary. 

In  conditions  where  the  tumor  is  remote  from  the  posterior  vaginal 


492  Pelvic  Hcematocele. 

cul-de-sac,  projecting  toward  the  abdominal  wall,  and  when  the 
cavity  is  exceedingly  large,  I  have  practiced  subperitonaeal  laparo- 
tomy with  success  in  one  case.  This  operation  consists  essentiaUy 
in  a  long  incision  parallel  to  the  crural  arch,  the  detachment  of  the 
peritonaeum  as  far  as  the  tumor,  and  penetration  through  the 
surface  attached  to  the  pelvis  without  opening  the  peritonseal  cavity. 
After  haraig  emptied  the  cyst  with  care,  the  sac  is  explored  by 
introducing  the  finger,  in  order  to  find,  by  combining  tins  exam- 
ination with  vaginal  touch,  the  favorable  point  for  the  passage  of  a 
drainage  tube  through  the  vagina.  This  located,  the  cruciform 
drainage-tube  is  introduced  through  the  posterior  vaginal  cul-de-sac. 
If  the  sac  is  large,  vaginal  may  be  combined  with  abdominal 
drainage. 

Laparotomy  properly  so-called,  or  trans-peritonseal  laparotomy, 
has  given  good  results.  It  is  necessary,  if  possible,  to  fix  the  sac 
to  the  abdominal  wall  by  a  veritable  marsupialization,  to  empty, 
tampon,  and  drain  it.  But  this  theoretical  procedm-e  is  rarely 
practicable  and  we  may  be  obliged,  then,  to  confine  ourselves  to 
antiseptic  irrigation  of  the  cavity.  It  would  be  better  in  such  eases 
to  practice  capillary  drainage  and  tamponnement  with  iodoform 
gauze.  Transperitonseal  laparotomy,  it  appears  to  me,  should 
rarely  be  done,  on  account  of  the  grave  danger  of  septic  peritonitis. 

Extra-peritonseal  hsematocele. — jEtiology. — It  may  occur 
under  the  influence  of  pregnancy,  as  this  causes  a  considerable 
dilatation  of  the  whole  venous  system  of  the  pelvis  and  in  particular 
of  the  utero-ovarian  plexus.  But  utero-ovarian  varicocele  may 
exist  and  give  rise  to  a  subserous  rupture,  even  in  the  non-gra^id 
state,  by  rupture  or  ulceration  of  veins  containing  phlebolites.  It 
is  generally  under  the  influence  of  fatigue  or  sexual  excess  during 
the  menstrual  period  that  this  is  observed,  and  inmultiparse  whose 
veins  are  more  dilated  than  in  women  who  have  never  had  children. 
Skene  Keith  has  called  attention  to  the  fact  that  an  ephemeral 
extra-peritonfeal  hematocele  often  follows  after  salpingotomies. 

Pathological  anatomy. — The  blood  forms  a  circumscribed  tumor 
between  the  two  folds  of  the  broad  ligament.  As  it  does  not  con- 
stitute a  closed  cavity,  but  communicates  with  the  pelvic  cellular 
tissue,  the  sanguineous  effusion,  if  it  is  very  abundant,  exceeds 
these  limits.  It  is  then  carried  along  on  the  sides  of  the  vagina  and 
rectum.  The  tumor  is  usually  of  moderate  size  and  varying  from 
that  of  the  fist  to  that  of  an  adult  head.  It  is  markedly  lateral,  and 
if  a  tumor  exists  on  both  sides,  one  is  always  much  greater  than  the 
other.  The  two  tumors  may,  furthermore,  be  united.  The  collection 
is  sometimes  even  situated  in  front  of  the  uterus.  A.  Martin,  who 
has  had  occasion  to  study  the  pathological  anatomy  in  several 
operations,  has  always  found  a  pocket  of  kregular  shape  marked 
by  diverticula  which  pass  deeply  into  the  connective  tissue.     The 


Pelvic  Hcematocele.  493 

contents  consist  of  blood  and  more  or  less  altered  clots — are  some- 
times mixed  with  pus.  It  may  communicate  with  an  intra-peritonaeal 
effusion  by  a  rupture  of  the  broad  ligament. 

Symptoms.- — ^The  accident  occurs  among  women  apparently  in 
perfect  health.  An  acute  pain  in  the  lower  part  of  the  abdomen 
with  tendency  to  syncope  marks  the  onset.  Several  successive 
attacks  may  be  observed.  The  symptoms  of  intense  anaemia  and 
of  pressure  on  the  bladder  and  rectum  appear  at  the  same  time 
with  the  swelling  and  the  sensitiveness  of  the  abdomen.  On  bi- 
manual examination  it  is  found  that  the  tumor  is  situated  in  the 
broad  ligament  and  not  in  Douglas'  cul-de-sac ;  and  is  soft  and 
doughy ;  the  uterus  is  found  on  its  inner  side,  it  is  more  or  less 
pushed  backward  but  can  be  circumscribed  in  every  direction. 
With  regard  to  the  other  symptoms  and  the  progress  of  the  disease, 
they  resemble  the  clinical  picture  of  intra-peritonteal  hsematocele. 
There  are  some  eases  of  extra-peritonseal  hsmatocele  in  which 
there  occurs  a  very  exceptional  symptom,  an  ecchymotic  dis- 
coloration of  the  vagina.  Ecchymosis  of  the  abdominal  wall,  even, 
has  been  seen  in  very  rare  cases. 

The  differential  diagnosis  from  intra-peritonseal  hsematocele  can 
not  always  be  made.  It  will  depend  especially  on  the  aetiology  and 
on  the  markedly  lateral  situation  and  the  relations  of  the  tumor. 

Treatment. — Expectation  is  here,  again,  the  usual  rule.  If  the 
gravity  of  the  symptoms  demand  interference,  opening  through  the 
vagina  will  be  dangerous  on  account  of  the  risk  of  wounding  the 
large  vessel  and  the  ureters.  Subperitonseal  laparotomy,  it  appears 
to  me,  should  have  the  choice.  Martin  advises  trans-peritoneal 
laparotomy.     He  has  had  nine  successes  in  ten  operations. 


494  Extra-Uterine  Pregnancy. 


CHAPTER  XXXVII. 


EXTRA-UTERINE   PREGNANCY. 

Extra-uterine  or  ectopic  pregnancy  is  the  development  of  the 
fecundated  o-^ule  outside  the  normal  iiterme  cavity. 

Pathogenesis ;  JEtiologij. — All  conditions  -which  tend  to  prevent  the 
application  of  the  tube  to  the  ovary  at  the  moment  of  rupture  of  a 
foUicle  are  favorable  to  fecundation  in  an  abnormal  situation.  It 
is  known  that  the  spermatozoids  can  penetrate  into  the  perito- 
nfeal  cavity  and  remain  ahve  there,  and  also  that  the  ovules  may 
fall  into  the  same  cavity  and  make  extensive  migrations  without 
losing  their  vitahty.  The  adhesions  of  the  appendages  following 
partial  peritonitis,  frequent  sequellse  of  salpingitis,  loss  of  the 
ciliated  epitheleum  of  the  tube,  or  an  obstacle  to  the  migration  of 
the  ovule  occasioned  by  a  small  intra-tubal  polypus,  are  the  most 
fi-equent  causes.  Emotional  disturbance  at  the  time  of  conception 
has  also  been  invoked.  This  affection  is  rare  :  out  of  sixty  thousand 
women  examined  during  seven  years  in  the  clinics  of  Carl  Braun 
and  of  Spaeth,  at  Vienna,  only  five  cases  have  been  found.  This 
number  appears  to  be  too  small.  Fasola  has  observed  five  cases 
out  of  one  thousand  five  hundred  and  sixty-five  pregnancies  among 
women  haA"ing  had  childi'en,  but  remaining  sterile  a  long  time  after. 

Division. — The  numerous  anatomical  divisions  and  subdivisions 
that  have  been  proposed  are  of  httle  interest.  The  immense  majority 
of  fcetal  cysts  are  found  in  the  tube  and  are  tubal  pregnancies. 
According  to  the  location  of  the  ovum  we  have  tubal  pregnancy, 
properly  so-called  :  tubo-uterine  or  interstitial  pregnancy,  andtubo- 
abdominal  pregnancy,  under  which  may  be  included  a  sub-variety 
tubo-ovariau  pregnancy.  If  the  tube  ruptures  and  the  develop- 
ment of  the  foetus  continues  in  the  peritonsal  cavity,  the  pregnancy 
becomes  secondary  abdominal  pregnancy.  This,  according  to  some 
authors,  may  also  be  primary.  If  the  rupture  occurs  in  the  non-ad- 
herent border  of  the  tube  the  foetus  may  continue  to  develop  in  the 
thickness  of  the  broad  ligament,  producing  a  pelvic  subperitonseal 
pregnancy.  Finally,  although  more  limited  in  mimber  than  formerly 
believed,  there  exist  some  cases  of  development  of  the  ovum  at 
the  surface  of  the  ovaiy,  or  ovarian  pregnancy,  that  are  differ- 
entiated by  certain  anatomical  characters  from  abdominal  preg- 
nancy. Pregnancy  in  a  rudimentary  conm  of  the  uterus  differs  so 
much  from  normal  pregnancy,  with  regard  to  the  fcetal  cyst,  that  it 
deserves  to  be  mentioned  in  connection  ^vith  extra-uterine  preg- 


Extra-  Uterine  Pregnancy. 


495 


nancy,  from  which  it  is  distinguished  with  difficulty.  For  this 
reason  the  term  ectopic  pregnancy  would  be  preferable  to  that  of 
extra-uterine  pregnancy. 


Fig.  257. — Tubal  pregnancy  of  two  a  a  half  months;   the  sac  is  intact  (Bouilly). 

Pathological  anatomy. — Tuhal  i)regnancy j)roperly  so-called. — Out  of 
one  hundred  and  twenty-two  cases,  Henuig  has  found  that  in 
seventy-seven  the  o^nam  was  situated  in  the  middle  of  the  tube. 
The  other  cases  were  divided  thus  :  ten  near  the  uterus,  seventeen 
almost  in  the  middle  of  the  tube,  eight  in  the  external  third,  five  in 
the  external  fourth.  At  least  twelve  cases  of  tubal  pregnancy  at 
term  are  known. 

As  soon  as  the  o\aile  becomes  fixed  the  tubal  mucosa  undergoes 
a  transformation  approximating  that  of  the  uterine  decidua. 
Piokitansky  has  described  the  flocculent  appearance  of  the  mucosa, 
the  villi  of  which  are  entangled  with  those  of  the  chorion.  The 
adhesion  is  of  moderate  firmness  up  to  the  moment  of  the  formation 
of  the  placenta.  The  uterine  orifice  of  the  tube  may  remain  open 
in  such  a  manner  that  the  transformation  of  the  mucosa  extends  to 
that  of  the  uterus. 

In  the  first  three  months  the  small  tumor  that  is  met  on  opening 
the  abdomen,  has  nothing  to  distinguish  it  fi'om  the  ordinary 
hsematosalpinx,  for  blood  is  usually  effused  into  its  canity.  It  has 
the  form  of  an  egg  or  of  a  bagpipe  (Fig.  257),  and  contains  either 
a  transparent  liquid,  in  which  the  embryo  floats,  or  clots,  more  or 
less  recent,  sometimes  stratified  like  those  of  an  aneurysmal  sac. 
It  may  then  be  difficult  to  find  the  small  foetus.  Often,  search  for 
villi  of  the  chorion  will  be  the  only  means  of  determining  the  nature 
of  the  tubal  cyst.     This  tumor  is  usually  pedunculated,  but  some- 


496 


Extra-  Uterine  Pregnaiicy. 


times  extensively  adherent  to  the  broad  ligament  into  which  it 
burrows  more  or  less,  separating  its  folds.  Earelj'  the  walls  of  the 
cyst  are  thin  and  transparent,  to  such  an  extent  that  the  embryo  is 
visible  thi-ough  them.  Henuig  has  noticed  that  the  muscular  wall 
is  hypertropbied  at  tbe  end  of  the  second  month ;  later,  under  the 
influence  of  distention,  it  is  thinned  and  frayed.  Early  rupture  is 
the  ordinary  termination  of  tubal  pregnancy.  The  dimensions  of 
the  rupti:red  cyst  do  not  generally  exceed  those  of  a  hen's  egg. 
Kaltenbach  has  noted,  as  the  immediate  cause  of  mpture,  the  ad- 
hesions which  oppose  the  expansion  of  the  cyst.  The  rupture  of 
very  vascular  adhesions  is  in  itself  the  cause  of  grave  haemorrhage. 
Freund  found  in  a  unique  ease  that  the  ruptm-e  of  the  tube  was  due 
to  its  myxomatous  degeneration. 


Fig.  25S. — Tubal  pregnancy  of  tn  o  and  a  half  months; 
the  sac  laid  open  (Bouillyl. 

The  rupture  of  the  tube  generaUy  occurs  into  the  peritoneal 
cavity  and  cause  the  fulminant  variety  of  haematocele  that  Barnes 
has  called  cataclysmic.  If  it  occurs  in  the  depth  of  the  broad 
ligament,  there  results  an  extra-peritonaeal  hfematocele,  and  the 
resistance  of  the  folds  of  tbe  hgament  has  tbe  effect  of  limiting  the 
hfemorrhage. 

The  evolution  of  tubal  pregnancy  may  be  very  different.  In 
exceptional  cases,  the  embryo  succumbs  early,  is  disintegi-ated  and 
leaves  no  traces.  The  tubal  sac  ceases  to  gi-ow  but  the  internal 
hsemorrhage  which  accompanies  the  death  of  the  embryo  transforms 
this  sac  into  a  haematosalpinx.  This  accident  changes  its  chnical 
nature  and  its  prognosis.  It  is  M-ith  difficulty  that  the  sm-geon,  in 
remo^•hlg  it  later,  recognizes  its  origin.  It  is  even  possible  that  a 
complete  resorption  of  the  contents  of  tbe  tube  may  occur.     This  is 


Extra-  Uterine  Pregnancy. 


497 


the  result  expected  by  those  who  expect  to  cause  death  of  the  foetus 
by  injections  of  morphine  or  by  electricity.  If  the  fcetus  succumbs 
at  a  later  period,  it  constitutes  a  foreign  body  which  may  become 
encysted  and  transformed  into  a  lithopedion,  or  induce  accidents 
leading  to  its  elimination. 


Fig.  259. — Extra-uterine  tubal  pregnancy,  ruptured.  Td,  right  tube  in  which  is 
seen  the  rupture  D  below  the  embroy  E;  Od,  Ld,  ovary  and  round  ligament  of  the 
right  side;  Tg,  Lg,  left  ovary  and  round  ligament;  C,  cervix.  (Preparation  deposited 
in  the  museum  of  legal  medicine  at  Vienna  by  Hofmann). 

Finally,  the  foetus  may  live  up  to  term.  TMs  especially  occurs 
when  rupture  takes  place  into  the  broad  ligament,  the  separated 
folds  of  which  protect  the  included  fcetus  from  escaping  into  the 
abdominal  cavity. 

Tuho-uterine  or  interstitial  pregnancy. — Here  the  ovum  develops  in 
the  very  short  intramural  portion  of  the  tube.  It  is  free  for  that 
part  of  its  surface  which  false  membranes  separate  from  the  peri- 
tonaeal  cavity.  When  the  f cetal  cyst  ruptures,  there  may  be  haemor- 
rhage by  the  natural  passages.  The  placenta  and  even  the  fcetus 
may  be  expelled  in  this  direction  or  fall  into  the  peritonEeum.  The 
usual  duration  of  this  variety  is  generally  longer  than  the  pre- 
ceding ,  it  may  even  reach  term,  but  it  usually  terminates  by  a 
fatal  haemorrhage  before  the  fourth  month.  According  to  Schultz, 
this  is  a  frequent  variety  and  often  unrecognized. 

Tubo-ahdominal  pregnancy. — The  o^oim  develops  at  the  external 
extremity  of  the  tube,  and  is  only  partially  enveloped  by  it,  the 
external  portion  of  the  sac  being  formed  by  false  membranes.  It 
is  adherent  to  the  contiguous  parts.  The  placenta  usually  occupies 
the  pelvic  cavity.  The  ovary  may  be  flattened  and  blended  with 
the  walls  of  the  sac  in  such  a  way  that  the  pregnancy  is  properly 


498  Extra-Uterine  Pregnancy. 

termed  a  tubo-ovarian  pregnancy.  The  possible  extension  of  the 
cyst  into  the  abdominal  ca^•ity  by  the  successive  addition  of  false 
membranes,  makes  it  possible  to  see  how  the  rupture  may  some- 
times iDostpones  until  term.  It  is  also  possible  that  many  tubo- 
ovarian  and  even  ovarian  pregnancies  should  have  another  origin. 
Yulliet  maintained  that  pregnancy  is  sometimes  developed  in  a 
pre-existing  tubo-ovarian  cyst. 


c 

Fig.  260. — Interstitial  extra-uterine  pregnancy,  ruptured.  D,  rupture;  C,  cervix; 
Td,  Ld,  tube  and  round  ligament  of  the  right  side;  Tg,  Lg,  left  tube  and  round 
ligament.  (Preparation  deposited  in  the  museum  of  legal  medicine  at  Vienna  by 
Hofmann). 

Ovarian  pregnancy  has  been  disputed.  Many  cases  that  have 
been  reported  were  veritable  tubo-abdominal  pregnancies  with 
intimate  secondary  adhesion  to  the  ovary.  It  is  not  impossible, 
however,  that  fecundation  may  occur  in  the  Grafdan  foUicle  in  such 
a  manner  that  the  placenta  is  inserted  in  the  ovarian  tissue,  but 
such  facts  are  very  rare.  Heineken  regards  as  ovarian  pregnancy 
only  that  form  where  the  placenta  is  found  in  the  interior  of  the 
ovary.  Worth  says  that  in  analyzing  the  pecuHarities  which 
characterize  ovarian  pregnancy,  there  remains  only  a  single  positive 
fact,  but  that  of  the  greatest  importance  for  anatomical  diagnosis, 
that  is,  a  foetal  sac  manifestlj'  proceeding  from  the  appendages,  and 
a  condition  of  the  fallopian  tube,  such  as  to  preclude  aU  possibility 
of  its  participation  in  the  formation  of  the  foetal  sac. 

Ahdominal  pregnancy . — When  the  ovule  falls  into  the  peritoneal 
cavity  and  is  fecundated,  it  may  go  thi-ough  the  phases  of  its 
development.  It  is  most  commonly  enveloped  in  a  pseudo  mem- 
branous  sac,  which  may  become  very  thick,  by  the  addition  of 


Extra-  Uterine  Pregnancy. 


499 


.successive  layers,  and  adhere  strongly  to  the  contiguous  organs. 
In  rare  cases  the  fcetus  may  be  enclosed  only  in  a  thin  and  trans- 
parent membrane,  but  an  extreme  vascularization  is  produced  in 
the  contiguous  organs.  There  is  nothing  resembling  a  decidua. 
The  placenta  has  no  regular  form,  and  it  may  attain  enormous 
proportions.  Unless  pressure  prevents,  the  development  of  the 
foetus  may  become  complete,  and  may  not  be  interrupted  by  rupture 
or  hemorrhages.  The  placental  circulation  has  been  known  to 
survive  the  foetus  and  to  cause  a  fatal  haemorrhage.  But  usually 
this  circulation  ceases  by  degrees,  and  is  completely  abolished  two 
months  after  the  death  of  the  embryo.  It  has  been  maintained 
that  abdominal  pregnancy  is  always  secondary  to  the  rupture  of  a 
tubal  cyst.  This  organ  is  probably  the  most  frequent,  but  some 
carefully-observed  cases  establish  the  reality  of  primary  abdominal 
pregnancy. 


Fig.  261. — Ectopic  pregnancy  in  a  rudimentary  cornu  of  the  uterus,  ruptured.  Cd, 
right  cornu,  the  seat  of  the  pregnancy;  O  d,  right  ovary;  Td,  right  tube;  Ld,  right 
round  ligament;  Cg,  Og,  Tg,  L g,  left  cornu,  ovary,  tube  and  round  ligament;  Va, 
vagina;  V,  bladder.  (Preparation  deposited  in  the  museum  of  legal  medicine  at  Vienna 
by  Hofmann). 

Pregnancy  developed  in  a  rudimentary  uterine  cornu. — Facts  of  this 
variety  are  often  badly  interpreted  and  wrongly  attributed  to  a  tubal 
pregnancy.  It  is  difficult,  at  the  autopsy,  to  determine  whether 
the  cyst  is  developed  in  the  tube  (interstitial  variety)  or  in  a  rudi- 
mentary cornu  of  the  uterus.  The  diagnosis  is  impossible  in  the 
living  subject.  What  adds  to  the  difficulty  is  the  fact  that  the  tumor 
developed  in  the  rudimentary  cornu  is  separated  from  the  rest  of 
the  uterus  by  a  pedicle,  detaching  this  sac  from  the  rest  of  the 
organ  (Fig.  261).  An  attentive  examination  will  show  the  character- 
istic relations  of  the  tube  and  round  ligament  with  the  cyst.  In 
tubal  pregnancy  the  tube  is  very  much  diminished  and  the  round 
ligament  is  situated  at  the  internal  part  of  the  sac.    In  case  of 


500  Extra-Uterine  Pregnancy, 

a  gravid  rudimentary  cornu  the  tube  has  preserved  its  whole  length 
and  its  insertion  as  well  as  that  of  the  round  ligament  is  found  at 
the  external  part  of  the  sac. 

State  of  the  uterus  in  extra-uterine  pregnancy. — There  is  a  general 
hypertrophy  of  the  organ  which  enlarges  its  cavity ;  at  the  same 
time  the  mucosa  is  modified  in  a  manner  that  is  wholly  analogous 
to  that  of  the  gra^dd  uterus.  The  changes  are  marked  in  pro- 
portion to  the  proximity  of  the  ovum  to  the  uterus.  The  situation 
of  the  uterus  varies  with  that  of  the  ovum.  At  the  third  or  foui-th 
month  the  o^Tim  generally  occupies  Douglas'  cul-de-sac  and  the 
uterus  is  pushed  forward  and  more  or  less  to  one  side.  The  ovary 
of  the  same  side  as  the  embryo  generally  contains  a  large  corpus 
luteum.  Cases  of  normal  pregnancy  have  been  observed  in  con- 
nection with  an  extra-uterine  pregnancy. 

Anatomical  changes  supervening  upon  the  death  of  the  fatus. — The 
fcetal  cyst  may  rupture  early  and  cause  fatal  accidents,  or  it  may 
produce  a  retro-uterine  htematocele,  in  which  the  presence  of  an 
embryo  soon  becomes  unrecognizable.  If  the  foetus  reaches  term, 
its  life  is  prolonged  a  little  beyond  the  natural  limit,  then  it  dies. 
One  of  two  events  may  then  occur :  either  it  is  not  tolerated  and 
causes  accidents  which  terminate  in  the  death  of  the  patient  or  in 
the  expulsion  of  the  foetal  debris ;  or,  the  foreign  body  is  tolerated 
and  undergoes  metamorphoses  which  tend  to  fatty  degeneration  and 
calcification. 

Symp>toms  of  ectopic  pregnancy. — The  woman  may  present  all  the 
signs  of  an  ordinary  pregnancy.  Agaui,  all  symptoms  may  be 
absent  or  at  least  so  little  marked  as  to  cause  no  suspicion  of  the 
presence  of  a  foetus.  The  expulsion  of  a  decidua  and  the  increase 
in  the  size  of  the  abdomen  are  the  symptoms  which  give  warning. 
However,  in  the  great  majority  of  cases,  this  last  symptom  is  but 
shghtly  marked  before  rupture  follows  in  the  second  or  thiixl  mouth. 
The  symptoms  then  are  those  of  an  internal  haemorrhage,  and  are 
sometimes  abruptly  developed.  After  a  first  attack  the  patient 
may  recover  and  then  present  new  ones.  Death  is  then  produced 
after  two  or  thi-ee  attacks,  or  even  more  slowly  by  successive 
haemorrhages.  I  wiU  not  return  to  the  symptoms  of  the  internal 
haemorrhage  and  of  the  haematocele  which  may  succeed  to  the 
rupture,  as  they  have  akeady  been  presented. 

When  the  pregnancy  approaches  term,  as  may  happen  especially 
in  the  intra-ligamentous  and  the  abdominal  variety,  sjmiptoms  of 
pressure  on  the  bladder  and  the  rectum  are  observed,  and  recurrent 
inflammatory  phenomena.  The  patient  is  usually  confined  to  bed 
with  fever  and  pain.  Freund  has  obsei-ved  intestinal  colic  and 
diarrhoea,  proceeding  from  the  irritation  of  the  intestine  to  which 
the  foetal  cyst  is  attached.  Compression  of  the  rectum  may  cause 
intestinal  occlusion. 


Extra-Uterine  Pregnancy.  501 

The  pains  may  assume  an  expulsive  character  at  a  period  more 
or  less  remote  from  the  time  accouchement  should  take  place.  The 
cyst  then  ruptures  into  the  abdomen  and  the  patient  succumbs  to 
an  acute  or  chronic  peritonitis,  sometimes  septic.  If  this  crisis  is 
passed,  the  patient  enters  upon  a  condition  of  tolerance  of  the 
foreigia  body,  which  is  resorbed  or  transformed  into  a  lithopedion. 
But  this  period  may  be  again  interrupted  by  grave  inflammatory 
accidents,  when  all  danger  seemed  to  have  passed.  Another  case 
may  pursue  another  course ;  the  rupture  may  occur  into  the  folds 
of  the  broad  ligament.  The  hffimorrhage  then  is  less,  it  remains 
limited,  and  the  symptoms  are  less  grave.  Besides,  if  the  foetus 
continues  to  live,  the  extra-peritonseal  development  of  the  ovum  is 
more  favorable  for  the  success  of  a  subsequent  operation.  Finally, 
in  exceedingly  rare  cases,  the  rupture  may  take  place  into  the  uterus 
itself.  Spontaneous  expulsion  and  evacuation  of  the  contents  of 
the  cyst  may  occur  also  after  suppuration.  This  occurs  most 
fi-equently  by  perforation  thi-ough  the  abdominal  walls  or  by  per- 
foration of  the  rectum.  More  rarely,  perforation  takes  place  into 
the  vagina  or  bladder. 

Diagnosis. — For  purposes  of  diagnois  it  is  indispensable  to  divide 
extra-uterine  pregnancy  into  periods,  for  each  of  which  there  is  a 
very  definite  type. 

1.  Before  the  fifth  month;  Embryonic  period  of  the  ovum,  to  the 
moment  xvhen  there  are  signs  of  life. — This  is  incomparably  the 
commonest  case,  and  is  also  that  which  gives  rise  to  the  greatest 
uncertainties.  It  is  true  these  have  no  great  importance  in  the 
therapeutic  point  of  view,  as  we  shaU  see.  Tliis  period  corresponds 
to  the  first  four  or  five  months  of  foetal  life ;  but,  if  the  foetus  is 
dead  and  development  stops,  it  may  last  much  longer  without 
appreciable  change,  unless  an  accident  (rupture,  inflammation  of 
the  cyst)  intervenes. 

The  rational  symptoms  present  nothing  striking.  There  are 
more  or  less  marked  disturbances  of  the  genital  organs  responding 
to  the  uterine  syndrome.  Menorrhagia  may  be  especially  noted. 
At  other  times  the  menstruation  is  not  disturbed.  All  the  signs  of 
a  normal  pregnancy  may  be  present  in  the  beginning.  To  avoid 
confusion  the  exact  dimensions  of  the  uterus  may  be  determined 
by  bimanual  palpation ;  its  size  does  not  correspond  to  the  stage 
of  gestation.  The  expulsion  of  a  decidua,  following  attacks  of 
colic,  is  often  the  indication  of  a  disturbance  in  the  life  of  the  ovum 
and  of  the  death  of  the  embryo.  The  pregnancy  may  continue, 
however,  after  the  expulsion  of  the  decidua,  which  may  be  mistaken 
for  abortion,  especially  if  metrorrhagia  exists  at  the  same  time. 
But  after  this  expulsion,  the  tumor  persists  if  there  is  an  extra- 
uterine pregnancy,  while  it  disappears  after  a  miscarriage. 

Painful    symptoms,    due    to    intestinal    adhesion,    have    been 


502  Extra-Uterine  Pregnancy. 

especially  marked  in  case  of  tubo-abdominal  or  abdominal-ectopie 
pregnancy.  When  the  oTum  is  situated  in  Douglas'  cul-de-sac, 
grave  syioptoms  have  been  observed  fi-om  compression  of  the  ureters 
and  of  the  rectum.  The  ectopic  fruit  sac  has  in  such  cases  been 
mistaken  for  a  fibroid  of  the  posterior  surface  of  the  uterus. 

By  bimanual  exploration  there  is  felt  at  the  side  of  the  uterus, 
often  fused  Avith  it,  sometimes  separated  by  a  sulcus  and  a  pedicle, 
a  tumor  which  differs  in  no  way  from  the  more  frequent  tubal 
tumors,  hydro-,  haemato-  orpyosalpins.  When  the  tumor  is  situated 
in  Douglas'  cul-de-sac,  ballottement  may  be  obtained  toward  the 
end  of  the  fourth  month. 

2.  After  the  fifth  month ;  foetal  period. — In  an  ectopic  pregnancy 
that  has  passed  the  fifth  month,  the  sympathetic  phenomena  of 
gestation  persist,  accompanied  with  abdominal  pains  that  are 
sometimes  very  acute,  and  may  compel  the  patient  to  keep  her  bed. 
These  pams,  with  the  losses  of  blood,  the  irregularity  and  the  lateral 
situation  of  the  tumor,  distinguish  it  from  normal  pregnancy.  The 
eervix  is  much  less  softened  than  in  utero-gestation  and  bimanual 
exploration  shows  that  the  uterus  is  not  dilated,  at  least,  in  its  lower 
segment,  and  that  it  is  pushed  to  the  side  opposite  the  tumor.  The 
diagnosis  of  this  variety  of  ectopic  pregnancy  is  impossible. 

The  diagnosis  of  spurious  labor  is  imposed  when  expulsive  pains 
occur.  This  false  labor  usuaUy  comes  on  at  term,  sometimes, 
however,  at  the  seventh  month.  This  painful  crisis  should  not  be 
confounded  with  the  symptoms  of  rupture.  The  death  of  the  foetus 
is  announced  by  the  cessation  of  the  heart  sounds,  by  the  decrease 
in  volume  and  the  softening  of  the  tumor.  Fistulse  caused  by  the 
spontaneous  evacuation  of  fcetal  cysts  after  suppuration  are  recog- 
nized by  the  debris  of  the  fcetal  skeleton. 

Prognosis. — In  the  first  half  of  ectopic  pregnancylthe  great  danger 
lies  in  the  rupture.  On  the  contrary,  radical  operation  for  ablation 
of  the  fcetal  cyst  is  of  little  gravity  during  this  period.  In  the 
second  period  the  condition  is  quite  different.  At  this  time  the 
affection  is  grave  in  itself,  and  also  grave  as  to  treatment,  and  the 
gravity  of  the  operation  increases  in  proportion  as  the  end  of 
pregnancy  is  approached.  It  is  impossible  to  collect  the  mortuary 
statistics  of  the  ectopic  pregnancy  when  left  to  itself.  Spontaneous 
recovery  often  occurs  by  elimination  of  the  cyst  by  suppuration. 
Pregnancy  in  a  rudimentary  eornu  is  also  very  fatal  if  left  to  itself. 

Treatment. — One  fact  dominates  all  the  therapeutics  of  ectopic 
pregnancy ;  at  all  periods  of  its  evolution  it  is  a  constant  menace  to 
the  life  of  the  patient.  There  is  danger  of  fcetal  h;-emorrhage  in  the 
first  period;  danger  of  peritonitis  and  septicfemia  in  the  second, 
and  danger  of  suppuration  and  pressure  effects,  even  when  it  has 
long  been  transformed  into  substances  apparently  inert.     For  this 


Extra-Uterine  Pregnancy.  503 

reason  Werth  lays  down  the  proposition  that  extra-uterine  preg- 
nancy is  a  malignant  neoplasm  and  should  be  treated  as  such. 
The  therapeutic  question,  with  regard  to  indications,  is  thus  much 
simplified.  It  is  reduced  to  a  question  of  opportunity  for  operation 
and  to  a  question  of  technique  for  the  extirpation  of  the  fcetus. 

I  cannot,  however,  pass  in  silence  over  certain  methods  of  treat- 
ment, some  of  which  have  only  an  liistorical  value,  while  others 
still  have  warm  partisans.  They  all  pertain  to  the  first  period  of 
ectopic  gestation  and  aim  at  the  death  of  the  foetus,  hoping  for  its 
subsequent  resorption  or  toleration.  Among  the  condemned  meas- 
ures I  will  mention,  fasting,  strychnine,  ergotine,  mercurial  frictions, 
iodide  of  potassium,  repeated  blood-letting,  puncture  of  the  cyst. 
Two  methods  of  causing  early  death  of  the  foetus  are  stUl  discussed, 
the  injection  of  morphine  into  the  sac  and  the  application  of 
electricity. 

With  regard  to  injections  of  morphine,  they  may  give  rise  to 
grave  accidents,  to  haemorrhage,  to  septicaemia,  or  to  perforation  of 
the  intestine.  Now  in  all  the  cases  where  it  might  be  efficacious 
laparotomy,  in  the  hands  of  an  experienced  surgeon,  is  an  operation 
of  but  little  gravity. 

Electricity  has  been  employed  in  different  ways,  by  electro- 
puncture,  by  galvanization,  or  by  faradization.  The  last  method 
appears  to  be  used  almost  exclusively.  It  is  very  difficult  to  reach 
a  just  estimate  of  its  efficacy  as  we  have  no  means  of  estimating 
the  accuracy  of  diagnosis,  and  as  the  majority  of  the  observations 
have  been  published  by  practitioners  whose  authority  is  not  es- 
tablished. It  is  far  from  being  without  danger,  and  it  leads  to 
temporizing  in  the  face  of  a  menacing  lesion.  It  may  be  the 
du'ect  cause  of  tubal  contractions  and  rupture.  Brothers  has 
collected  two  cases  of  death.     Janvrin  has  also  cited  one. 

The  extraction  of  the  foetus,  with  or  without  the  sac,  by  laparotomy 
or  by  elytrotomy  (vaginal  incision)  is  the  treatment  at  all  stages  of 
extra-uterine  pregnancy.  We  may  make  the  following  classes  of 
cases : 

1.  Extra-uterine  pregnancy  before  the  fifth  month  ivithout  riq]tu're. — 
As  positive  signs  of  pregnancy  are  not  present  at  this  period,  we 
can  only  suspect  it.  But  the  presence  of  a  tumor  of  the  appendages 
occasioning  pain  is  sufficient  to  indicate  laparotomy.  The  operation 
then  does  not  differ  materially  from  the  extraction  of  a  serous, 
sanguineous  or  purulent  cyst  of  the  tube.  If  the  sac  is  not 
pedunculated,  as  for  example  in  pelvic  subperitonjeal  pregnancy, 
a  decortication  of  the  sac  is  made,  incising  the  serous  capsule  first, 
in  a  spot  where  there  are  no  vessels.  The  profuse  hfemorrhage 
caused  by  the  placenta,  even  at  this  early  period,  is  controlled  by 
its  immediate  extirpation.    Tamponnement  of  the  peritonaeum  with 


504  Extra-Uterine  Pregnancy. 

iodoform  gauze  would  render  material  service  here.  Elytrotomy 
has  been  practiced  in  the  first  four  mouths  of  extra-uterine  preg- 
nancy. ■  It  is  decidedly  inferior  to  laparotomy. 

2.  Extra-uterhie  pregnancy  before  the  fifth  month,  complicated  with 
rupture  and  dangerous  hcemorrJtage. — When  a  hemorrhage  menaces 
the  life  of  a  patient  its  source  must  be  sought  at  once,  whether  it 
be  internal  or  external.  To  temporize,  to  count  on  spontaneous 
hsemostasis,  is,  in  the  great  majority  of  cases,  to  leave  the  woman 
to  die.  If  she  does  not  succumb  at  once,  she  will  fi-om  a  second  or 
from  a  third  haemorrhage,  or  from  the  complications  of  an  haema- 
tocele.  Swarz  recommends  careful  removal  of  all  the  blood,  and 
advises  not  to  count  on  the  absorbent  power  of  the  peritonaeum  in 
case  of  profuse  haemorrhage.  Htemostatic  tampounement  of  the 
peritonaeum  with  iodoform  gauze  may  be  employed,  if  necessary. 

3.  Extra-uterine  j^regnancy  after  the  fifth  month;  fa^tus  living. — The 
fact  that  the  foetus  is  alive  has  a  great  importance  bearing  on  the 
choice  of  procedure.  But  it  has  been  appreciated  differently  by 
different  authorities.  Some  see  in  this  the  possibility  of  an 
operation  which  saves  both  the  mother  and  the  child.  Others  are 
occupied  exclusively  with  the  possibility  of  saving  the  mother  and 
with  the  gi-eater  gi-avity  of  interference  when  the  placental  circu- 
lation is  in  full  activity.  The  partisans  of  the  primary  operation 
remark  that  while  operations  made  after  the  death  of  the  foetus  are 
less  liable  to  haemorrhage,  there  is  greater  danger  of  septicaemia. 
Finally,  the  life  of  the  foetus  has  certainly  been  too  much  disre- 
garded. Numerous  cases  where  the  child  has  lived  are  known  to- 
day. If  then,  by  improvement  in  the  technique,  the  chances  for 
the  mother  can  be  made  as  good  in  an  operation  before  as  after  the 
death  of  the  foetus  the  former  should  certainly  be  preferred.  It 
must  be  admitted  that  the  results  have  not,  until  recently,  been 
encoui'aging.  But  the  aspect  of  the  question  has  changed,  the 
great  majority  of  the  recent  operations  have  been  successful.  This 
success  appears  to  be  due  principally  to  the  recent  improvement 
in  the  technique  and  in  particular  to  the  extirpation  of  the  sac  and 
the  placenta. 

It  remains  to  decide  the  choice  of  operation  destined  for  extraction 
of  the  foetus.  As  a  general  rule,  laparotomy  is  indicated.  How- 
ever, elytrotomy  should  not  be  entii'ely  proscribed. 

4.  Extra-uterine  jjregnancy  after  the  fifth  month;  recent  death  of  tJie 
foetus. — Should  laparotomy  be  made  in  the  first  few  days  after  the 
death  of  the  foetus  ?  The  majority  of  authors  decide  in  the  negative. 
In  consideration  of  the  fact,  however,  that  the  length  of  term 
required  for  obliteration  of  the  placental  circulation  is  doubtful,  and 
that  septiciemia  and  intercurrent  peritonitis  may  comphcate  a  late 
operation  which  some  months  sooner  would  have  been  a  compara- 
tively simple  one,  there  is  much  to  be  said  for  early  operation. 


Extra-Uterine  Pregnane^/.  505 

Here,  as  in  almost  all  the  problems  of  abdominal  therapeutics,  the 
theoretical  objections  of  timid  surgeons  fall  before  the  brilliant 
results  of  a  bold  practice,  skiUfully  executed.  The  invasion  of 
fever,  and  the  prodramata  of  septicaemia,  far  from  being  a  contra- 
indication, make  the  operation  imperative. 

5.  Extra-uterine  pregnancy  after  theffth  month. — Foetus  dead  a  long 
time. — When  the  foetus  has  long  been  dead,  when  tolerance  appears 
established,  and  there  is  hope  of  seeing  it  transformed  into  a 
lithopedion,  is  it  wise  to  interfere  and  subject  the  woman  to  the 
dangers  of  laparotomy  ?  I  believe  that  even  then  operation  should 
be  advised,  in  view  of  the  dangers  of  the  future.  It  must  be 
remembered  that  the  continued  tolerance  of  the  foetus  is  always 
uncertain. 

6.  Siqjpurating  foetal  cyst  of  long  sta7iding,  with  or  icithout  fistula. — 
It  is  evidently  necessary  to  hasten  the  slow  processes  of  nature.  If 
abscess  exist,  it  should  be  opened.  The  existence  of  a  fistula  will 
often  serve  as  a  guide  for  the  incision  of  the  sac.  Such  operations 
are  usually  benign  if  care  is  taken  with  the  antisepsis  of  the  sac. 

7.  Pregnancy  in  a  rudimentary  uterine  cornii. — Left  to  themselves 
the^  cases  have  given  a  mortality  of  twenty-three  out  of  thirty  in 
the  first  six  months  (Bandl).  Operation  by  laparotomy  should 
promptly  intervene.  It  has  been  performed  six  times,  with  five 
successes,  at  full  term  or  long  after  it.  The  supplementary  cornu 
is  removed  as  the  whole  uterus  is  in  Porro's  operation. 

Teclmique  of  extraction  of  the  foetus  by  laparotomy. — I  have  no 
intention  of  describing  the  whole  operation,  as  the  same  rules  apply 
here  as  in  hysterectomy  and  ovaritomy.  I  shall  limit  myself  to 
insisting  on  some  special  and  particularly  difficult  points.  Haemor- 
rhage is  greatly  to  be  feared,  when  in  a  pregnancy  sufficiently 
advanced,  the  foetus  is  living  or  only  a  short  time  dead.  Care  must 
therefore  be  taken  to  avoid  wounding  the  placenta  in  opening  the 
sac.  If,  on  examining  the  relations  of  the  tumor,  it  is  found  that 
the  total  ablation  of  the  sac  would  be  extremely  difficult,  this  plan 
should  be  abandoned  at  once  and  the  sac  should  be  united  to  the 
abdominal  wall  with  sutures.  Great  care  must  be  taken  to  avoid 
traction  on  the  cord  or  placenta.  The  best  means  of  controlling  the 
haemorrhage  is  firm  tamponnement  with  iodoform  gauze.  In  any 
case  of  haemorrhage,  a  loose  tamponnement  of  the  sac  with  iodoform 
gauze  should  be  made.  The  tampon  may  be  left  three  or  four 
days  without  fear  of  decomposition;  if  it  has  been  used  to  combat 
a  hasmorrhage  it  should  not  be  removed  before  the  eighth  day. 

Infection  of  the  peritonaeum  by  the  contents  of  a  foetal  cyst  is  to 
be  feared  in  operating  after  the  death  of  the  foetus,  and  when  the 
patient  has  fever  indicating  a  putrid  resorption.  Every  effort 
should  be  made  to  extirpate  the  entire  sac  without  opening  it. 

Consolation  of  the  sac  is  to  be  recommended  when   complete 


506  Extra-Uterine  Pregnancy. 

eniioleation  mtbout  rupture  presents  too  gi-eat  dif3ficulties.  One  pro- 
cedure consists  in  tamponing  the  wound  up  to  the  sac  with  iodoform 
gauze  for  three  daj's,  and  then  opening  the  cyst  after  it  has  become 
adherent  to  the  abdominal  wall.  If  prompt  action  is  necessary  the 
sac  should  be  united  to  the  integument  of  the  wound  by  a  row  of 
stitches  or  by  a  continuous  suture.  In  placing  the  sutures,  the 
needle  must  not  be  allowed  to  penetrate  into  the  interior  of  the 
sac.  After  opening  the  sac  the  fcetus  is  extracted  by  the  feet  and 
the  cord  cut  between  two  ligatures.  The  cavity  must  be  carefully 
cleansed  with  a  sublimate  solution  (1-200)  or  with  a  saturated 
solution  of  napthol.  The  cavity  of  the  sac  is  explored,  and  if  it  is 
in  close  proximity  with  the  vaginal  eul-de-sae,  the  cruciform  drain- 
age-tube is  introduced.  The  placenta  may  be  mumified  by  the  use 
of  a  mixture  of  powdered  tannin  and  salicylic  acid,  or  with  powdered 
sodium  benzoate.  Strips  of  gauze  are  packed  into  the  sac  and 
care  is  taken  that  no  fluid  accumulates.  Eecoveiy  takes  place  by 
gi-anulation,  the  placenta  being  detached  piecemeal. 

The  technique  of  the  management  of  the  sac  may  be  summed  up 
as  follows : 

First  stage. — Abdominal  incision,  provisional  suture  of  the  sac 
to  each  end  of  the  lips  of  the  wound. 

Second  stage. — Opening  of  the  sac  in  its  thinnest  part,  avoiding 
the  vessels  as  much  as  possible  and  using  forci-pressure  as 
necessary. 

Third  stage. — Extraction  of  the  foetus  by  gi-asping  the  feet, 
Hgature  and  division  of  the  cord. 

Fourth  Stage. — Removal  of  the  provisional  sutures,  extraction 
of  the  sac  by  separating  its  adhesions  and  decortication  of  the  sub- 
serous portion,  forceps  being  quickly  placed  on  the  bleeding  points, 
which  the  assistant  has  compressed  with  the  fingers,  as  required. 

Fifth  stage. — Permanent  hsmostasis  of  the  base  of  the  wound 
by  ligatures  or  by  tamponnement  with  iodoform  gauze.  Even 
when  tamponnement  has  not  been  employed,  it  is  well  to  leave  the 
lower  portion  of  the  abdominal  wound  open  and  drain  by  means  of 
a  rubber  tube  or  strips  of  iodoform  gauze. 

Technique  of  extraction,  of  the  foetus  hy  elytrotomy. — Pinard's 
method  is  as  follows  :  Ansiesthesia ;  exploration  of  the  vaginal  cul- 
de-sac  and  puncture  with  the  knife  at  a  point  where  the  absence  of 
arterial  pulsation  has  been  ascertained.  Introduction  of  the  finger 
into  the  buttonhole  for  exploration,  then  enlargement  by  multiple 
incisions  and  dilatation  by  the  use  of  the  fingers.  The  hand  pressed 
into  the  sac  grasps  the  feet  and  brings  them  to  the  vulva  by  slow 
and  continued  traction.  Then  the  trunk  and  the  breech  are  en- 
gaged. The  two  arms  are  successively  disengaged  and  then  the 
head  extracted.  The  cord  is  cut  and  search  is  made  for  the 
placenta.     If  it  can  be  easily  removed,  it  is  gently  detached  with 


Extra-Uterine  Pregnancy.  507 

the  fingers ;  if  it  adheres,  no  matter  how  little,  it  is  better  to  leave 
it.  The  cavity  of  the  cyst  is  then  washed  out  freely  with  a  subli- 
mate solution,  1-5000,  or  a  saturated  aqueous  solution  of  napthol 
b.  I  am  inclined  to  tliink  that  the  introduction  of  iodoform  gauze 
would  be  preferable  to  the  frequent  injection  advised  by  Pinard  ; 
the  gauze  may  be  removed  every  three  or  four  days,  and  might  be 
left  even  longer  in  place.  If  symptoms  of  putrid  infection  appear 
by  reason  of  insufficient  antisepsis,  continuous  irrigation  might  be 
used. 

Spontaneous  extension  of  the  suppurating  fcetus  by  the  bladder 
is  very  rare.  Winckel,  in  a  recent  work,  has  collected  twelve  pub- 
lished cases.  Laparotomy,  opening  through  the  vagina  (P.  Muller), 
elytrotomy,  subpubic  section,  have  been  practiced  in  these  cases 
(Werth).  These  operations  can  generally  be  avoided ;  it  is  sufficient 
to  dilate  the  urethra  (Winckel),  and,  if  necessary,  to  incise  it 
(Littlewood)  to  be  able  to  search  for  the  orifice  of  the  sac  with  the 
index  finger,  to  enlarge  it,  by  extracting  the  bones  of  the  fcetus  with 
the  forceps,  then  to  cleanse  it  by  injections.  It  is  only  when  tliis 
does  not  succeed,  and  when  serious  accidents  demand  active  inter- 
ference that  vaginal  section  should  be  done,  followed  by  immediate 
suture  after  evacuation  and  disinfection  of  the  sac.  The  operation 
through  the  dilated  urethra,  may,  however,  be  made  in  two  or  three 
sittings,  with  the  help  of  cocaine.  Carbolized  injections  of  the 
bladder  should  be  continued  till  all  traces  of  cystitis  has  disappeared. 

Perhaps  in  certain  cases,  when  a  large  cyst  is  strongly  wedged  in 
Douglas'  cul-de-sac,  perineotomy,  either  transverse  or  vertical, 
would  be  preferable  to  elytrotomy,  or  the  para-sacral  incision,  or 
even  the  pelvic  operation  might  be  resorted  to  after  preliminary 
resection  of  the  coccyx  and  part  of  the  sacrum.  Future  experience 
must  determine  the  application  of  these  new  operations. 


508  Vaginitis. 


CHAPTER  XXXVIII. 


VAGINITIS. 

Pathogemj;  ^Etiology. — The  mucosa  which  lines  the  vagina,  like 
all  those  in  immediate  contact  with  the  air,  is  a  dermo-papillary 
mucous  membrane  closely  resembling  the  integument  in  its  serrated 
framework  and  its  stratified  epithelial  covering.  But  it  is  dis- 
tinguished by  the  absence  of  the  impermeable  layer  of  the  skin 
formed  by  the  corneous  portion  of  the  epidermis.  The  constant 
desquamation  of  epithelial  cells,  incessantly  renewed  at  its  surface, 
alone  protects  it  against  the  effect  of  external  initants.  It  is 
difficult  to  understand,  however,  how  this  mucosa  resists  the  action 
of  the  numerous  germs  which  multiply  in  its  cavity,  unless  the 
recent  discoveries  with  regard  to  the  resisting  power  of  the  tissues 
doubtless  serve  to  explain  it.  The  vagina  is  normally  inhabited 
by  mdifferent  germs,  some  of  which  are  of  a  pathogenetic  species, 
although  inoffensive  by  their  attenuation ;  it  receives  morbid  germs 
which  come  from  without  by  the  simple  entrance  of  an.-,  by  coitus, 
by  injections,  etc.  Inoculation  occurs,  however,  in  special  con- 
ditions which  permit  germs  to  acquu'e  or  to  manifest  theii-  virulence. 
The  irritation  of  the  older  authors  is  insufficient.  Thus  a  deep 
cauterization  ■n-ith  a  caustic  only  causes  a  localized  lesion  without 
inflammation  communicated  to  the  rest  of  the  canal,  provided 
cleansing  injections  prevent  the  stagnation  of  the  hquids,  while  the 
same  lesion,  or  the  sojourn  of  a  foreign  body  otherwise  aseptic,  is 
sufficient  to  develop  an  intense  vaginitis,  if  cleanliness  be  neglected 
and  the  proliferation  of  micro-organisms  be  thus  favored. 

Blennorrhagic  infection  stands  in  the  first  rank  in  thestiology  of 
vaginitis,  on  account  of  the  tenacity  of  the  inflammation  to  which 
it  gives  rise  and  the  gravity  of  its  complications.  Since  Xeisser's 
discovery,  it  is  known  that  the  pathogenetic  germ  of  this  afifection 
is  a  special  coccus  that  has  been  called  gonoeoccus  (Fig.  262).  It 
presents  in  the  form  of  roimded  or  oval  gi-anules,  like  gi-ains  of 
coffee,  adherent  sometimes  by  their  plane  surface,  having  an  oiit- 
line  of  the  shape  of  a  figure  8.  United  in  groups  of  ten  to  twenty, 
they  form  colonies  enclosed  in  a  hyahne  envelope.  They  are 
susceptible  to  staining  with  methyl  violet  or  fuchsin.  The  role  of 
the  gonoeocci  has  long  been  unquestioned.  It  is  proven  beyond 
dispute. 

The  pathogenic  microbes  of  supiDuration  and  of  putrefaction  also 
give  rise  to  vaginitis.     These  germs  may  come  from  without,  the 


Vaginitis. 


509 


gaping  of  the  vulva  favors  their  entrance ;  on  the  other  hand,  the 
presence  of  a  hymeu  with  a  narrow  orifice  may  also  have  an  effect 
by  retaining  the  menstrual  blood  in  a  retro-hymeneal  cul-de-sac. 
Such  is  the  predisposing  cause  of  non-specific  vaginitis  of  young 
girls  and  virgins,  in  whom  masturbation  sometimes  adds  the  influ- 
ence of  a  direct  inoculation.  Inflammations  of  the  vulva  of  various 
kinds  may  also  be  the  means  of  infection.  Ascarides  fi-om  the 
rectum  are  frequently  a  cause.  It  is  sufficient  to  mention  the 
transmission  of  infectious  material  from  the  rectum  and  bladder  by 
fistulse  as  an  exceptional  cause.  But  a  frequent  cause,  often  un- 
recognized, is  secondary  infection  of  the  vagina  by  pathological 
secretions  fi-om  the  uterus. 


R. 

Fig,  262. — Microbes  of  blennorrhagia  (gonococcus  of  Neisser).  A.  Section  of  the 
palpebral  conjunctiva  in  a  case  of  blennorrhagic  ophthalmia.  Migration  of  the  gono- 
cocci  (Bumm).  B.  Preparation  from  the  vaginal  secretion  of  a  parturient  woman,  a, 
epithelial  cell,  vifith  bacilli  and  gonococci ;  i,  pure  culture  of  gonococci;  c,  schema  of 
the  gonococcus  (Bumm). 

In  a  purely  cHnical  point  of  view,  a  number  of  types  may  be  dis- 
tinguished : 

1.  The  blennorrhagic  vaginitis  of  adults,  which  is  much  the  most 
common  form.  It  may  also  affect  young  girls  and  virgins,  in 
whom  its  true  origin  is  often  unrecognized. 

2.  The  vaginitis  of  young  gii-ls  and  virgins,  which  may  be  of 
blennorrhagic  origin,  as  I  have  said.  But  there  exists  a  non- 
specific vaginitis  due  to  the  development  of  simple  saprophytes,  in 
feeble  children,  surrounded  by  bad  hygienic  conditions.  I  have 
alluded  to  the  role  of  ascarides  in  young  girls,  and  of  narrowness  of 
the  hymeneal  orifice  in  virgins. 


no 


Vaginitis. 


3.  The  vaginitis  of  pregnant  women  is  sometimes  only  the  re- 
awakening of  an  old  gonorrhoea,  Ijut  it  may  also  be  non-specific. 
It  is  then  due,  without  doubt,  to  infection  by  staphyloceoei  or  by 
streptococci.  With  the  exception  of  the  septic  yaginitis  of  partu- 
rient women,  this  is  never  a  definite  morbid  species,  it  is  the  simple 
local  manifestation  of  a  general  infection. 

4.  The  vaginitis  of  the  menopause  and  of  the  aged,  generally 
assumes  a  form  peculiar  to  itself  The  absence  of  hygienic  care 
and  of  a  predisposing  diathesis,  may  usually  be  invoked  as  an 
explanation. 


Fig.  263. — Granular  vaginitis  (Ruge). 

Pathological  anatomy. — The  vaginal  canal  is  rarely  affected  to  its 
whole  extent.  This  may  be  observed,  however,  in  the  acute  stage 
of  an  inflammation  caused  by  a  recent  blennorrhagia,  by  an  exan- 
them,  or  by  an  acute  local  ii-ritation.  Then  the  mucosa  is  found 
swollen,  red  and  covered  with  muco-pus.  More  frequently  the  in- 
flammation is  in  patches.  Diseased  areas  alternate  ■«ith  healthy 
ones. 


Fig.  264. — Simple  vaginitis  (Ruge). 

C.  Euge  has  distinguished  thi-ee  forms  of  vaginitis,  in  a  patho- 
logical point  of -siew :  1.  Granular  vaginitis.  2.  Simple  vaginitis. 
3.  Senile  vaginitis.  A  fourth,  emphysematous  vaginitis,  might  be 
added,  but  this  rare  lesion  should  not  be  made  a  separate  morbid 
entity. 

1.  Granular  vaginitis. — This  is  the  most  frequent  form.  The 
epithehal  covering  is  thickened,  especially  in  its  deep  layers.  The 
papillffi  are  hypertrophied,  infiltrated  with  round  cells  and  fused  to 
form  the  small  masses  which  constitute  the  granulations.  The  epi- 
thelium which  covers  these  bodies  becomes  thin  and  assumes  a 


Vaginitis.  511 

granular  aspect  that  makes  it  difficult  to  distinguish  from  the  tissues 
of  the  granulation  (Fig.  263). 

2.  Simple  vaginitis. — The  epithelial  surface  remains  smooth,  but 
thickened  in  places.  In  the  parts  where  it  is  thinnest  the  papillae 
are  tumefied  and  the  subjacent  tissue  presents  an  infiltration  of 
round  cells.  But  the  proliferation  is  confined  to  the  epithelial 
layer  (Fig.  264). 

3.  Senile  vaginitis. — More  or  less  extensive  islets  project  at  the 
surface  of  the  mucosa.  Sometimes  there  are  ecchymoses.  Some- 
times the  flattened  projections  present  at  their  centers  a  point  of 
softening.  The  epithelial  covering  is  very  thin  or  destroyed  and 
permits  the  formation  of  adhesions,  which  may  result  in  obliteration 
of  the  vagina.  The  mihary  form,  described  by  Eppinger,  appears 
to  belong  to  this  form,  as  well  as  the  adhesive  vaginitis  of  Hilde- 
brand.  It  is  probable  that  this  also  belongs  to  what  has  been 
called  leucoplasia  of  the  vaginal  mucosa. 

4.  Emphysematous  vaginitis  or  cystic  pachyvaginitis. — This  form  is 
very  rare  outside  of  pregnancy.  It  has  been  called  cystic  colpo- 
hyperplasia. As  it  is  not  in  true  cystic  cavities  that  the  gas 
infiltrates,  but  in  the  meshes  of  the  connective  tissue,  it  is  more 
properly  called  emphysematous  vaginitis.  It  is  probable  that  the 
gas  is  formed  in  consequence  of  molecular  degeneration  of  the 
tissues  of  inflammatory  proliferation,  although  this  origin  remains 
to  be  demonstrated.  Chiari  affirms  that  the  gas  develops  in  the 
enlarged  capillaries  of  the  lymphatic  system. 

Symptoms. — At  the  onset,  if  the  vaginitis  results  from  a  blennor- 
rhagic  infection  from  traumatism,  a  sharp  local  pain  may  mark 
the  invasion  of  the  disease.  With  this  is  soon  associated  leucor- 
rhcea,  at  first  serous,  then  greenish  white,  puriform  or  markedly 
purulent.  It  may  be  extremely  copious  and  give  rise  to  a  painful 
pruritus.  After  the  acute  period  the  flow  is  diminished  in  amount. 
Digital  examination  reveals  a  granular  and  rugous  condition  of  the 
vagina.  It  is  hot  and  painful  in  the  acute  stage.  In  blennorrhagic 
vaginitis  urethritis  always  exists  at  the  same  time.  The  general 
health  is  often  affected  by  the  excessive  leucorrhoea.  Senile  vaginitis 
frequently  causes  no  symptoms  or  only  a  leucorrhcea,  that  is  serous 
or  tinted  with  blood.  This  chronic  vaginitis  causes  a  loss  of  tonicity 
and  favors  vaginal  prolapsus.  The  emphysematous  vaginitis  of 
parturient  women  is  also  limited  to  the  production  of  leucorrhoea. 
The  expulsion  of  sections  of  the  mucosa,  following  astringent 
injections  or  simply  in  violent  inflammation,  has  been  termed 
exfoliative  vaginitis.  It  is  only  a  rare  epiphenomenon  and  should 
not  be  confounded  with  the  expulsion  of  an  iutra-uterine  membrane. 

Diagnosis. — The  true  difficult}'  of  the  diagnosis  consists  in  the 
determining  whether  the  vaginitis  is  blennorrhagic  or  not.  The 
absence  of  the  gonococcus  is  not  conclusive.     The  presence  of  an 


512  Vaginitis. 

urethi'itis  is,  on  the  contrary,  a  of  proof  the  blennorrhagic  nature  of 
the  disease.  The  progress  of  the  disease,  the  antecedents  of  the 
patient,  will  also  furnish  important  information.  The  presence  of 
vegetations  is  a  strong  presumption.  The  coexisting  inflammation 
of  Bartholin's  glands  is  an  almost  positive  indication  of  blennor- 
rhagic infection. 

Prognosis. — Blennorrhagic  vaginitis  is  a  grave  affection  on  account 
of  its  propagation  to  the  cervix,  to  the  uterus  and  to  the  tubes.  It 
is  also  very  obstinate,  and  old  inflammations  which  appear  extinct 
may  be  rekindled  under  the  influence  of  any  exciting  cause,  excess 
of  coitus,  chill  during  the  menses,  excessive  fatigue,  puerperal  state, 
etc.  Blennorrhagia,  in  women,  is  incomparably  more  serious  than 
in  men.  More  frequently  in  women  than  in  men  the  ascending 
lesions  are  bilateral  and  cause  sterihty.  Obliteration  of  both  tubes 
by  chi'onic  salpingitis  is  the  rule  in  prostitutes.  What  especially 
constitutes  the  gravity  of  blennorrhagia  in  women,  is  that  an  ap- 
parently insignificant  remnant  of  infection  in  the  cervex,  may, 
under  the  influence  of  the  puerperal  state,  regain  all  its  former 
virulence,  be  combined  with  septic  infection  (mixed  infection, 
puerperal  gonorrhcea)  and  cause  the  most  serious  results.  The 
extreme  importance  of  a  prompt  and  energetic  treatment  is  then 
apparent.  The  opinion  of  Noggerath  on  the  incurability  of  this 
disease  is  not  too  radical,  unless  the  patient  is  promptly  and  en- 
ergetic aUy  cared  for. 

The  danger  of  blennorrhagia  in  littte  gii-ls  hes  in  the  fact  that  it 
may  extend,  as  with  adults,  to  the  utenis,  the  tubes,  or  the  perito- 
naeum. Saxinger  has  observed  pyosalpingits,  in  vii'gins,  which 
could  be  explained  only  by  gonorrhceal  infection  by  contact,  without 
coitus.  A  case  of  generalized  peritonitis,  reported  by  Welander, 
occurred  in  a  httle  gii-1  of  five  years.  These  facts  are  exceedingly 
rare,  but  death  by  suppurating  pelvic  peritonitis,  following  pyo- 
salpinx,  may,  very  often,  be  the  consequence  of  blennorrhagic 
infection.  Other  varieties  of  vaginitis  have  a  much  less  serious 
prognosis  and  yield  more  easily  to  treatment. 

Treatment. — -Fii-st  -nill  be  sought  the  causes  which  may  provoke 
or  maintain  the  chi-onic  inflammation,  a  pessary,  ascarides,  or 
cer\-ical  catarrh.  Many  cases  of  vaginitis  yield  to  the  treatment 
of  the  metritis  which  maintains  it.  It  is  thus  that  Schi'oeder's 
operation,  excision  of  the  mucosa  of  the  cervix,  is  the  best  means 
of  curing  chi-onic  vaginitis  caused  by  cerncal  infection  of  gonor- 
rhceal origin. 

For  chi'onic  granular  vaginitis  and  for  senile  vaginitis,  it  has 
been  found  useful  to  apply  every  other  day,  long  tampons  of  ab- 
sorbent cotton  soaked  in  borated  glycerine  or  glycerole  of  tannin. 
Painting  the  vagina  with  a  1-20  solution  of  nitrate  of  silver  is  a 
valuable  measure. 


Vaginitis.  513 

In  the  acute  stage  of  blennorrhagic  vaginitis  emollients  have 
been  advised.  It  is  certain  that  prolonged  baths  and  diluent  drinks 
relieve  the  uretlnritis  which  accompanies  inflammation  of  the 
vagina.  But  injections  of  marshmallow,  of  linseed,  etc.,  are  of 
very  doubtful  utility  and  may  be  even  injurious,  for  they  are  far 
from  being  antiseptic.  Better  to  make  large  irrigations  of  several 
litres  (4  to  6)  of  boiled  water,  with  a  small  quantity  of  sublimate 
(1-10000)  added.  A  small  glass  canula  is  employed,  gently  intro- 
duced on  account  of  the  great  sensitiveness  of  the  vagina.  As  soon 
as  it  can  be  tolerated,  the  wirework  speculum  will  be  useful.  It  is 
very  important  to  place  the  canula  after  each  irrigation,  in  a 
solution  of  carbolic  acid  of  50-1000,  otherwise  fresh  inoculations 
may  occur.     The  patient  must  be  kept  quiet. 

As  soon  as  the  subacute  period  is  passed,  an  energetic  antiseptic 
treatment  is  instituted :  injections  twice  a  day  with  a  sublimate 
solution,  1-2000,  taking  care  to  cleanse  the  cul-de-sac  with  the  aid  of 
the  finger  deeply  introduced ;  after  each  injection,  introduction  of  a 
tampon  of  iodoform  gauze,  the  size  of  a  pigeon's  egg,  moderately 
packed  against  the  cervix;  this  tampone  becomes  saturated  with 
the  secretions,  and  thus  acts  at  the  same  time  as  an  antiseptic,  an 
agent  of  drainage  and  of  absorption.  If  necessary,  the  injections 
of  sublimate  may  be  replaced  with  injections  of  creoline,  perman- 
ganate of  potash,  carbolic  acid,  boracic  acid,  alum,  tannin,  resor- 
cine,  or  chloral.  But  the  sublimate  is  incomparably  more  efficacious 
and  has  never  been  attended  with  accidents  in  my  hands  in  such 
cases.  Fritsch  has  advised  chloride  of  zinc  in  the  proportion  of 
ten  grammes  per  Ktre.  With  pregnant  women  injections  of  sub- 
limate should  be  made  only  with  great  care,  promoting  the  escape 
of  the  liquid  by  introduction  of  a  speculum,  because  of  the  great 
facility  with  which  mercurial  absorption  may  take  place. 

The  so-called  balsamic  treatment  is  directed  to  the  concomitant 
urethritis ;  but  copaiva,  or  cubebs  are  badly  tolerated  by  women 
and,  besides,  the  urethritis  is  incomparably  less  refractory  with 
them  than  with  men,  on  account  of  the  straightness,  the  shortness 
and  the  width  of  the  canal.  Iodoform  pencils  (caeco  butter  and 
iodoform),  introduced  into  the  canal  and  slightly  flattened  by 
pressing  tlu'ough  the  vagina,  are  very  useful  in  chronic  urethritis. 

When  the  treatment  of  the  vaginitis  is  sufficiently  advanced,  it  is 
well  to  attack  without  delay  the  metritis  which  may  have  resulted 
fi-om  it,  and  which  may  itself  maintain  the  remaining  inflammation 
of  the  vagina.  The  general  treatment  should  not  be  neglected. 
Ii'on  and  tonics  should  be  administered  to  chlorotic  women.  Scrof- 
ulous children  should  receive  the  treatment  appropriate  to  their 
condition. 

Foreign  authors  describe  under  the  name  of  croupous  or  diph- 
theritic  vaginitis  the    production  of    false    membranes    due    to 


614  Tumors  of  the  Vagina. 

superficial  necrosis  of  the  mucosa,  and  which  has  nothing  in  com- 
mon with  the  signiticauce  attaching  to  the  word  diphtheria ;  it  is 
only  gangi-eue  of  tlie  vagina,  a  more  exact  designation  than  gan- 
grenous vaginitis,  which  is  met  in  cases  of  intense  septic  infection 
of  the  vagina  or  in  some  cases  of  cancer  of  the  uterus,  of  sloughing 
fibroids,  or  pessaries  indefinitely  forgotten  in  the  vagina,  -v^-ithout 
care  or  cleanliness.  It  may  also  he  observed  in  cases  of  intense 
blennorrhagia,  in  the  puerperal  state,  and  in  the  course  of  acute 
infectious  diseases  (measles,  variola,  tj'phus).  This  is  not  a  distinct 
morbid  species,  but  a  septic  accident  gi-afted  on  inflammatory 
lesions  of  the  vagina.  It  does  not  furnish  any  new  indication  for 
treatment,  except  the  necessity  of  watching  the  adhesions  and 
retractions  which  may  follow  exfoliation  of  the  necrosed  parts  of 
the  mucosa.  For  this  purpose  antiseptic  tampons  are  used  in  the 
vagina  and  frequently  renewed.  Dissecting  phlegmonous  peri- 
vaginitis, or  suppurative  inflammation  of  the  cellular  tissue  around 
the  vagina  is  only  a  very  rare,  special  localization  of  pelvic  suppu- 
ration. It  has  been  observed  in  the  course  of  grave  fevers.  Its 
treatment  consists  in  giving  exit  to  the  pus  as  soon  as  it  is  recog- 
nized. 


CHAPTER  XXXVIX. 


TUMORS   OF   THE   VAGINA. 

Cysts. — Pathogeny. — A  glance  over  the  theories  that  have  been  ad- 
vanced with  reference  to  the  pathogeny  of  the  complex  clinical  gi-oup 
which  constitutes  cysts  of  the  vagina  ■nill  show  that  diverse  origins  are 
assigned  by  various  authors,  but  without  ascribing  any  of  them  to 
a  definite  anatomical  tj^pe.  One  origin  alone  appears  to  relate, 
■without  doubt,  to  a  certain  variety.  This  is  the  origin  fi'om  the 
Wolffian  bodies,  characterized  in  the  most  marked  cases  by  the 
presence  of  several  cysts  arranged  in  a  chaplet  or  in  a  superior 
prolongation  toward  the  broad  ligament.  AU  other  sources  are 
hypothetical.  I  believe  that  aU  large  cysts,  exceeding  the  size  of  a 
small  nut,  have  an  embryonic  origin.  With  regard  to  small  cysts, 
disseminated  over  the  whole  surface  or  over  a  limited  region  of  the 
vagina,  I  shaU  willingly  admit  their  pseudo  glandular  character. 

^Etiology. — Cysts  of  the  vagina  are  observed  at  all  ages.  It  is 
doubtful  if  excess  in  coitus  has  any  actual  influence.  Pregnancy 
may  act  by  producingtR  nutritive  superactivity. 


Tumors  of  the  Vagina.  515 

Pathological  anatomy. — The  wall  is  formed  by  fine  fibrillar  con- 
nective tissue.  It  sometimes  contains  muscular  fibres.  The  vaginal 
mucosa  usually  covers  the  cyst,  but  it  may  be  so  thumecl  and  fused 
with  the  wall  of  the  cyst  that  the  tumor  then  becomes  transparent. 
In  the  majority  of  cases  the  internal  surface  of  the  cyst  is  lined 
with  cylindrical  epithelium ;  sometimes  the  cavity  also  contains 
pavement  epithelium.  The  eccentric  compression  due  to  the  dis- 
tention of  the  sac  may  give  the  cylindrical  epithelium  a  flattened 
appearance.  Ciliated  epithelium  has  rarely  been  observed. 
Papillary  projections  from  the  internal  surface  have  been  seen. 
Kleinwachter  has  met  adenoid  degeneration  of  the  cyst  wall.  The 
contents  of  the  cyst  varies  in  its  color  and  in  its  consistence. 
Usually  it  is  viscous  and  transparent.     It  may  contain  pus  or  blood. 

Symptoms. — In  the  beginning  the  cyst  passes  unnoticed.  Usually 
the  first  sign  which  indicates  its  presence  is  the  vaginal  prolapsus. 
The  tumor  is  rounded,  smooth,  sessile,  or  with  a  tendency  to  become 
pedunculated  The  mucosa  covering  it  usually  preserves  its 
normal  color ;  it  is  rarely  thin  and  transparent.  It  is  often  difficult ' 
to  detect  fluctuation  when  the  cyst  is  small  and  tense.  It  may 
sometimes  be  felt  by  combined  rectal  and  vaginal  touch.  When 
the  cyst  acquires  some  size,  there  is  a  sense  of  weight  and  a  difficulty 
in  walking.  Leucorrhcea  may  be  induced  by  the  irritation  of  the 
tumor. 

Diagnosis. — Cysts  of  the  vagina  must  be  distinguished  from  the 
cystic  pachyvaginitis  that  is  characterized  by  the  presence  of 
numerous  small  cavities  in  the  deeper  portion  or  on  the  surface  of 
the  thickened  mucosa.  These  small  cavities  contain  gas  which 
escapes  on  puncture.  A  solitary  cyst  may  be  confounded  with 
cystocele,  with  urethrocele,  or  with  rectocele.  The  mistake  maybe 
avoided  by  combining  vaginal  examination  with  catheterization  or 
with  rectal  touch. 

Cysts  of  the  superior  third  of  the  vagina  may  be  difficult  to  dis- 
tinguish at  first  from  small  tumors  seated  in  Douglas' cul-de-sac, 
prolapsed  ovaries,  cystic  or  not,  inflamed  tubes,  nuclei  of  peri- 
salpingitis. An  attentive  examination,  under  anaesthesia  if  neces- 
sary, will  remove  all  doubts. 

Treatment. — Puncture  or  incision  alone  will  be  insufficient. 
Punctxire  followed  by  caustic  injections  is  liable  to  produce  an 
excessive  inflammation.  The  choice  lies  between  a  total  or  a 
partial  extirpation.  The  first  will  be  preferable  when  the  tumor  is 
easily  accessible.  However,  its  dissection  is,  even  then,  very  diffi- 
cult. It  is  almost  impossible  if  the  cyst  is  ruptured  during  the 
operation.  The  wound  is  immediately  united  with  a  continuous 
catgut  suture  in  superposed  rows. 

Partial  excision  will  be  preferable  for  cysts  situated  m  the  upper 
third  of  the  vagina  toward  the  posterior  wall.     The  cyst  is  trans- 


516 


Tumors  of  the  Vagina. 


fixed  with  a  tenaculum,  and  a  segment  of  the  sac  with  mucosa 
covering  it  is  removed  with  the  scissors.  The  remainder  of  the  sac 
is  packed  with  iodoform  gauze.  The  deep  portion,  which  is  not 
removed,  comes  awaj'  by  spontaneous  exfoliation. 


Fig.  265. — Section  of  the  wall  of  a  vaginal  cyst  (Schroeder). 

Fibrous  tumors  and  polypi. — Pathological  anatomy. — Fi- 
broids of  the  vagina  may  have  then-  origin  in  the  uterus  and  descend 
by  separating  the  recto- vaginal  septum,  but  there  also  are  tumors 
arising  in  the  vaginal  tissue  itself.  Their  structure  is  analogous  to 
that  of  uterine  fibroids.  The  most  frequent  seat  of  the  tumor  is  at 
the  upper  third  of  the  anterior  wall  of  the  vagina.  Their-  volume  is 
generally  smaU.  They  may  become  pedunculated  and  take  a 
polypoid  form.  Softening  and  cedema  has  been  noted.  They  may 
also  undergo  a  superficial  necrosis  and  vilcerate. 

They  have  been  especially  observed  at  middle  age,  but  cases  have 
been  reported  in  young  children. 

The  symptoms  depend  on  the  size  of  the  tumor.  If  very  small, 
they  pass  unnoticed  or  cause  only  a  slight  leucorrhoea.  If  larger, 
they  may  cause  hemorrhages  and  sj*mptoms  of  compression  of  the 
bladder. 

The  diagnosis  can  be  in  doubt  only  when  there  are  changes  in 
the  tumor  caused  by  cedema  or  ulceration.  They  might  then  be 
mistaken  for  cancer.  The  study  of  the  exact  relations  wiU  sei-ve  to 
distinguish  between  a  polypus  of  the  vagina  from  a  uterine  polypus, 
from  a  prolapsus  or  from  an  inversion.  The  treatment  consists  in 
the  enucleation  of  a  sessile  tumor  and  division  of  the  pedicle  in  ease 
of  a  polypus. 

Primary  cancer  of  the  vagina. — Primary  cancer  is  veiy 
rare.  A.  Martin  has  found  it  in  only  one  case  out  of  five  thousand 
women.  It  presents  tlu'ee  distinct  forms :  1.  Papillary,  or  vege- 
tating. 2.  Nodular,  or  infiltrating.  3.  Sarcoma,  either  diffused  or 
circumscribed.     Cancer  of  the  vagina  is  comparatively  frequent  in 


Tumors  of  the  Vagina.  517 

the  young,  but  it  is  especially  observed  at  the  middle  period  of  life. 
Kustner  has  noted  heredity  only  once.  Hegar  has  seen  cancer 
occur  about  the  border  of  an  ulceration  caused  by  a  pessary. 

An  epithelioma  of  papillary  form  usually  commences  on  the 
posterior  wall  of  the  vagina  with  the  appearance  of  an  excrescence 
havuag  a  broad  base  which  first  invades  the  cul-de-sac.  The  nodular 
form  of  epithelioma  begins  over  a  large  surface  in  isolated  spots 
which  rapidly  become  confluent.  Sarcoma  presents  two  varieties : 
1.  Diffuse  sarcoma  of  the  mucosa,  which  is  almost  always  the  form 
observed  in  small  children.  2.  Sarcomatous  fibroid,  a  slow  de- 
generation of  a  fibroid  or  of  a  polypus.  Melanotic  sarcoma  has 
been  observed. 

The  progress  of  vaginal  cancer  is  generally  rapid  except  the  fibro- 
sarcomatous  variety.  Extension  to  the  contiguous  parts  and  to  the 
lymphatics  occurs  rapidly. 

The  rational  symptoms  are  similar  to  those  of  cancer  of  the  cervix 
uteri :  There  are,  fetid  leucorrhoea,  haemorrhages,  pain,  and  pressure 
on  the  bladder  and  the  rectum. 

The  treatment  has  very  little  chance  of  producing  complete 
recovery,  but  it  is  possible  to  stop  the  progress  of  the  disease. 
Extirpation  will  be  attempted  only  in  case  it  is  possible  to  remove 
the  whole  neoplasm.  The  great  laxity  of  the  vaginal  walls  permits 
primary  union  of  very  extensive  wounds.  In  cases  where  there  is 
no  hope  of  removing  all  the  growth,  we  are  limited  to  curetting, 
followed  by  the  actual  cautery. 


618  Cicatricial  Fistula  of  the  Vagina. 


CHAPTER  XL^ 


CICATRICIAL  FISTUL-ffi   OF   THE   VAGINA. 

The  vagina  may  communicate  in  a  permanent  manner  with  the 
contiguous  viscera  thi-ough  cicatricial  openings  and  tracks,  or- 
ganized and  lined  with  epithelium.  These  abnormal  communi- 
cations, or  fistulie,  are  divided  into  two  classes  according  as  they 
give  passage  to  urine  or  to  fecal  material. 

Urinary  fistulse. — ^Etiology. — It  is  necessary  to  exclude  from 
the  class  of  fistulfe  properly  so-called,  or  cicatricial  fistulie,  the 
fistulous  communications  established  by  cancer,  at  an  advanced 
period.  In  the  gi-eat  majority  of  cases,  iistulse  originate  in  difficult 
labor  which  has  produced  necrosis  of  a  greater  or  less  extent  of  the 
genital  canal.  "When  the  foetal  head  remains  too  long  engaged  in 
the  inferior  strait,  the  vesico-vaginal  septum,  applied  against  the 
pubes,  is  compressed  strongly  and  becomes  necrotic,  if  this  pressure 
lasts  long,  as  in  cases  of  naiTow  pelvis,  of  excessive  size  of  the 
foetal  head,  or  of  presentation  of  the  shoulder.  It  is  the  duration 
more  than  the  intensity  of  the  pressure  that  is  to  be  feared.  Other 
causes  are  infinitely  more  rare.  Wounds  of  vesico-vaginal  septum 
by  the  forceps,  the  cephalotribe,  or  by  auy  cutting  instrament,  have 
been  followed  by  fistula.  Vesical  calcuh  and  iilcerations  of  the 
bladder  are  also  to  be  mentioned. 

Pathological  anatomy. — The  seat  of  fistulffi  is  variable,  and  depends 
uiDon  the  situation  of  the  bladder  and  of  the  urethra  relative  to  the 
superior  border  of  the  pubes  at  the  moment  of  labor.  The  body  of 
the  uterus  does  not  become  the  seat  of  a  fistula,  because  the  internal 
OS  is  always  found  above  the  pubes.  But  sloughing  of  the  anterior 
wall  of  the  cervix  may  occur,  giving  rise  to  a  vesico-uterine  fistula, 
or  more  exactly,  a  vesico-cervical  fistula.  The  bladder,  when  full, 
may  remain  above  the  sjTuphysis  and  draw  the  urethi-a  upward ; 
then  this  canal  sloughs,  from  pressm-e,  and  urethi-o-vaginal  fistula 
results.  Pressure  exerted  at  the  miion  of  the  superior  with  the 
middle  third  of  the  bladder  acts  upon  the  ureters,  and  may  cause 
a  uretero-cervical  or  a  uretero-vaginal  fistula,  accorduig  to  the  parts 
concerned. 

The  most  frequent  form  is  the  vesico- vaginal  fistula.  It  is  usually 
situated  high  up  iu  the  cul-de-sac.  Its  dimensions  are  sometimes 
very  small.  At  other  times  it  presents  a  gaping  orifice,  generally 
of  oval  form.  The  orifice  is  single  iu  the  majority  of  cases,  but  there 
may  be  several  openings,   separated  by  cicatricial  bridges.     The 


Cicatricial  Fistulce  of  the  Vagina.  519 

vagina  often  tolerates  the  incessant  contact  of  urine  very  well,  but 
it  may  also  be  the  seat  of  a  painful  chronic  inflammation.  This 
canal  sometimes  presents  cicatricial  bands,  narrowing  its  caliber. 
A  superior  diverticulum  may  be  produced,  that  allows  stagnation 
of  urine. 

Pure  uretero-vaginal  fistulre,  without  simultaneous  communi- 
cation with  the  bladder,  are  very  rare.  In  the  same  way  uretero- 
uterine  fistulae  are  only  a  particular  form  of  vesi co-uterine  or 
vesico-cervical  openings.  However,  at  the  end  of  some  time  the 
vesical  portion  of  the  fistula  may  become  obliterated  by  progressive 
concentric  contraction  while  the  perforation  of  the  ureter  persists. 

An  iniiammation  of  the  uterus  usually  accompanies  cases  of 
urinary  fistulas  which  keeps  the  cervix  in  a  state  of  constant  irri- 
tation.    The  alteration  of  the  cervical  mucosa  may  be  considerable. 

Symptoms. — When  an  accouchement  has  been  laborious  or  ac- 
companied with  violent  obstetrical  procedures,  an  involuntary  flow 
of  urine  is  sometimes  observed  soon  after.  It  is  possible  that  this 
may  be  the  result  of  a  laceration  of  the  vesico-vaginal  wall,  but  it 
is  equally  possible  that  it  may  result  from  a  traumatic  paralysis  of 
the  neck  of  the  bladder,  which  sometimes  precedes  the  exfoliation 
of  the  eschars  by  several  days.  Generally,  by  the  third  or  fourth 
day,  the  eschar  is  sufficiently  soft  to  allow  the  urine  to  pass,  drop  by 
drop  at  first,  then  freely,  as  it  becomes  detached.  The  quantity  of 
urine  which  flows  corresponds  with  the  size  of  the  orifice.  In 
ure  thro -vaginal  fistulae  the  urine  flows  into  the  vagina  only  at  the 
moment  of  micturition.  In  uretero-vaginal  or  uretero-uterine 
fistulffl,  the  urine  secreted  by  one  kidney  collects  normally  in  the 
bladder,  while  that  from  the  other  filters  into  the  vagina  drop  by 
di'op  or  in  small  jets.  The  constant  oozing  keeps  the  vulva  and 
thighs  in  a  constant  state  of  irritation.  The  general  health  may  be 
preserved.  In  many  cases,  however,  it  is  greatly  impaired  by  the 
influence  of  ascending  inflammations  of  the  genito-urinary  ap- 
paratus. 

Diagnosis. — Exploration  after  a  recent  delivery  should  be  made 
with  care,  and  if  any  doubt  remain,  an  injection,  colored  with  milk, 
should  be  tin-own  into  the  bladder,  after  previously  emptying  it.  If 
there  is  the  least  perforation,  the  liquid  will  creep  from  the  vagina. 
Touch  is  sufficient  means  of  diagnosis  in  large  fistulfe,  especially 
if  combined  with  the  use  of  a  sound  in  the  bladder.  But  exami- 
nation with  the  speculum  is  indispensable  to  acquire  exact  knowl- 
edge, and  to  discover  some  perforations  of  small  size.  Inspection 
may  be  hindered  by  cicatricial  bands  in  the  vagina,  resulting  from 
the  eschars.  They  may  be  drawn  aside  with  small  hooks,  while  a 
search  is  made  for  the  opening  of  the  fistula  with  a  small  probe. 
If  the  fistula  is  cervico-uterine,  the  use  of  a  sound  in  the  bladder 
and  of  a  stylet  in  the  cervix  will  detect  a  large  perforation.     For 


520  Cicatricial  Fistula  of  the  Vagina. 

small  perforations  it  may  be  necessary  to  use  vesical  injections  of 
miUi.  A  uretero-vaginal  fistula  ^YiU  be  suspected  when  the  opening 
is  situated  one  or  two  centimetres  from  the  cer^ix  on  the  sides  of 
the  vagina. 

Prognosis. — An  established  fistula  is  permanent  and  has  no 
tendency  to  spontaneous  cm-e.  The  cui'ability  of  fistulas  by  oper- 
ation depends  upon  the  situation,  the  extent,  the  age,  and  the 
simultaneous  alterations  of  the  vagina.  FistuliB  of  the  base  of  the 
bladder  are  more  easily  closed  than  vesico-cervical.  All  ureteral 
fistulfe  present  special  difficulties,  and  their  obliteration  is  liable  to 
result  in  stricture  of  the  ureter. 

Treatment. — Indications. — At  what  moment  is  it  expedient  to 
operate  ?  Hegar  and  Kaltenbach  fix  the  most  favorable  time  as 
between  the  sixth  and  eighth  week  after  delivery.  Age  is  not  a 
contra-indication;  bad  general  health  is  evidently  an  unfavorable 
condition  for  the  success  of  this  plastic  operation. 

In  every  vesico-  or  urethro- vaginal  fistula  the  incontinence  may 
be  cured :  1.  By  direct  obhteration  of  the  fistula ;  2.  By  obhte- 
ration  of  the  genital  canal  below  the  fistula,  thus  making  it  a  part 
of  the  urinary  reservoir.     This  procedui-e  is  evidently  a  last  resort. 


Fig.  266. — Neugebauer's  speculum. 

1.  Direct  obliteration  0/ fstuke  hij  iwimary  union. — Fikst  stage. 
• — The  position  of  the  patient  for  operation  varies  according  to  the 
dei)th  of  the  orifice.  The  dorso-sacral  is  sufficient  when  the  fistula 
is  near  the  vaginal  outlet.  Sims'  position  is  also  usefiil  in  some 
cases.  For  fistulae  very  high  up  the  genu-peetoral  position  is  prefer- 
able. It  has  the  disadvantage  of  making  the  management  of  the 
anaesthesia  more  difficult.  Neugebauer  employs  a  special  speculum, 
\\ith  hooks  di'a'wu  by  chains  to  separate  the  parts  about  the  field  of 
operation  (Figs.  266,  267,  268).  Anresthesia  by  chloroform  has 
generally  been  employed,  b^^t  I  have  used  cocaine  locally  with 
success.  Two  assistants  are  then  sufficient,  one  to  sei^arate  the 
vaginal  walls  and  keep  the  field  clear  of  blood,  the  other  to  help 
with  the  sutures.  The  operation  should  be  done  under  continuous 
h-rigation  ^Aih  sterihzed  water.  Bits  of  absorbent  cotton  held  in 
forceps  may  also  be  used  as  sponges.  The  periui^um  is  depressed 
with  a  Sims'  speculum.     A  sound  is  introduced  into  the  bladder  to 


Cicatricial  Fistulce  of  the  Vagina. 


521 


pusli  its  base  toward  the  surgeon.     Fiually,  the   cervix  is  fixed 
with  a  Tolsella. 


Fig.  267. — Neugebauer's  hooks  for  vesico- vaginal  fistula. 

Second  stage. — Denudation  of  the  lips  of  the  fistula. — Knives 
with  straight,  angular  or  curved  blades  are  used  in  preference  to 
the  scissors.  The  denudation  may  be  done  in  two  ways.  In  ordinary 
cases,  if  the  mucosa  is  normal  about  the  opening,  a  deep  infundi- 
buliform  denudation  is  made  (Fig.  271  mn).  In  cases  where  the 
cicatrices  are  extensive,  it  is  better  to  make  the  denudation  according 
to  the  American  method  (Fig.  271  x  y).  This  knife  is  held  obHquely 
and  sunk  in  the  vaginal  wall  at  a  distance  of  six  to  eight  milli- 
metres from  the  edge  of  the  opening,  so  that  its  point  perforates 
the  tissues  at  the  junction  of  the  vaginal  and  of  the  vesical  mucous 
membranes  and  passes  outside  the  cicatricial  tissue.  A  collar  is 
then  cut  from  around  the  fistula,  and  detached  finally  with  the 


522 


Cicatricial  Fistula  of  the  Vafjina. 


scissors  (Fig.  270).  The  shape  of  the  deuudation  in  small  j&stulae 
should  be  slightly  elliptical,  choosing  the  direction  in  M'hich  the 
suture  M"ill  produce  the  least  tension.  Care  is  taken  to  include  the 
vesical  mucosa  as  little  as  possible,  but  it  is  sometimes  impossible 
to  avoid  -nouuding  an  arteriole.  Bleeding  may  usually  be  controlled 
bj'  pressing  the  denuded  parts  between  the  fingers.  If  this  does 
not  succeed,  it  is  better  to  resort  to  the  suture  to  arrest  the  hsmor- 
orrhage  than  to  use  forcipressm-e.  This  is  the  method  for  denuding 
vesico-vaginal  or  urethi-o- vaginal  fistulse.  "When  the  fistula  is  near 
the  cervix,  it  may  be  useful  to  incise  the  anterior  lip,  or  even  to 
excise  a  cuniform  segment  in  such  a  way  as  to  lay  bare  the  fistulous 
orifice  (Fig.  274). 


Fig  26S  — Neugebauer's  speculum  and  retracting  hooks  m  pl-ice 

Thied  stage. — S'jf/Hrc— Many  operators  use  needles  mounted  in 
handles.  I  use  the  fine,  flat  Hagedorn  needles  exclusively,  as  the 
others  cause  too  large  perforations.  Fine  silk  or  silver  wire  is 
preferable  to  catgut.  Silkworm  gut  is  too  stiff.  There  are  first 
passed  a  series  of  deep  sutures  entering  at  five  millimetres  fi-om  the 
raw  surface,  passing  under  all  this  surface  and  avoiding  the  vesical 
mucosa  only.  Forceps  are  placed  provisionally  on  the  ends  of 
these  threads.  Between  these  deep  sutures  are  placed  superficial 
stitches,  intended  for  coaptation,  with  finer  threads  passed  as  near 
the  M'ound  as  possible.     These  are  tied  at  once  (Fig.  272)  and  then 


Cicatricial  Fistula  of  the  Vagina. 


523 


the  deeper  sutures.  If  it  be  possible  to  choose  the  direction  of  the 
hne  of  suture,  the  transverse  will  be  the  best.  If  the  perforation  be 
very  extensive,  it  will  be  well  to  give  it  the  form  of  a  Y  or  two  Ys 
(Figs.  275  and  276). 


Fig.  269. — Instruments  for  denudation  and  for  suture  in  vesico-vaginal  fistula. 
123,  knives,  straight,  convex  and  curved;  4,  spatula;  5  6,  blunt  and  sharp  hooks ;  7  S, 
wire-twisters;   9,  Collin's  forceps. 

Modifications  of  the  technique. — If  a  very  great  perforation  exists, 
or  if  the  edges  are  particularly  vascular,  it  is  better  not  to  denude 
all  around  the  fistula  at  once,  but  to  freshen  only  a  limited  portion 
and  suture  it  immediately,  proceeding  in  the  same  way  throughout. 
In  excessively  difficult  cases,  demanding  much  time,  the  operation 
may  be  done  in  several  sittings. 

When  the  vagina  is  very  narrow,  or  when  the  substance  is  wanting 
for  a  sufficient  denudation,  the  method  of  flap  splitting  may  be 
used.  In  cases  of  very  large  perforation  with  loss  of  substance, 
recourse  to  autoplasty  may  be  necessary.  Autoplasty  by  flap 
splitting  has  been  advised  by  Herff,  Sanger,  Pritsch  and  Walcher. 
The  last  reunites  the  lips  of  the  vesical  orifice  with  catgut,  and 
those  of  the  vaginal  wound  with  silk  (Figs.  277  and  278). 


524 


Cicatricial  Flstulce  of  the  Vagina.^ 


After-treatment. — After  the  termination  of  the  operation,  the 
vagina  is  irrigated  with  a  sublimate  solution,  1-2000,  and  the  Una 
of  suture  is  powdered  with  iodoform.  A  strip  of  iodoform  gauze  is 
placed  in  the  vagina  to  protect  the  posterior  waU  from  the  ends  of 


Fig  270. — Denudation  of  the  fistula. 

in        X 


Fig.  271. — Denudation  of  the  vesico-vaginal  fistula,  m  n,  infundibuliform  denu- 
dation (Simon) ;  x  y,  conical  denudation ;  P  o,  showing  the  economy  of  tissue  in  a 
large  cicatrix  that  Simon's  method  would  excise  on  ihe  line  rs. 


Cicatricial  Fistula  of  the  Vagi^ia. 


525 


the  sutures,  if  silver  wii-e  or  silkworm  gut  lias  been  used.  It  also 
absorbs  the  vaginal  and  the  uterine  secretions.  The  sutures  are 
removed  at  the  end  of  the  eighth  day.  I  leave  a  catheter  in  the 
bladder  for  forty-eight  hours,  then  it  is  removed  and  catheterism  is 
performed  every  three  hours  night  and  day.  This  should  be  con- 
tinued for  two  days  after  the  removal  of  the  stitches.  From  this 
time  vaginal  injections  of  a  sublimate  solution  are  given  morning 
and  evening. 


Fig.  272. — Suture  of  a  vesico- vaginal  fistula;  the  deep  and  the  superficial 
threads  are  in  place. 


Fig.  273. — Suture  of  a  vesico-vaginal  fistula ;  the  sutures  have  been  tied. 

1.  Indirect  obliteration  of  fistula. — There  are  conditions  in  which 
suture  of  a  vesico-vaginal  fistula  offers  no  chance  of  success.     We 


526  Cicatricial  Fistula  of  the  Vagina. 

may  fall  back  then  on  a  total  obliteration  of  the  genital  canal  as  a 
last  resort.  But  to  avoid  the  dangers  of  retention  of  the  menstrual 
blood,  the  communication  between  the  bladder  and  the  vagina  must 
be  of  sufficient  size. 


Fig.  274. — Operation  for  a  vesico-vaginal  fistula  near  the  cervix.  The  internal 
dotted  line  indicates  the  surface  to  be  denuded  around  the  fistula.  The  dotted  line  A 
B  indicates  the  detachment  of  the  mucosa  that  is  necessary  to  avoid  tension  (Emmet). 

First  stage. — Denudation. — The  vagina  should  be  obliterated  as 
high  up  as  possible.  A  ring  of  the  mucosa  is  denuded  to  a  width 
of  two  centimetres  by  commencing  the  dissection  from  above 
downward,  holding  the  contiguous  parts  tense  at  the  same  time  by 
the  use  of  forceps.  The  dissection  of  the  posterior  wall  is  aided  by 
a  finger  in  the  rectum,  and  that  of  the  anterior  wall  by  a  sound  in 
the  bladder.  The  surface  of  the  wound  is  carefully  smoothed  with 
the  cuiTed  scissors. 

Secoxd  stage. — The  sutures  are  made  with  silk,  using  a  large 
Hagedorn  needle  to  pass  them  deeply  under  all  the  sui'face  of  the 
wound,  first  from  below  upward,  then  fi-om  above  downward.  Care 
must  be  taken  not  to  penetrate  into  the  urethra,  rectum  or  perito- 
nseum.  As  soon  as  the  first  suture  is  placed  it  facilitates  the  rest 
of  the  operation  by  permitting  coaptation  of  the  parts.  In  tying  the 
sutures,  great  care  must  be  taken  not  to  overlap  the  tissues. 
Finally,  some  superficial  stitches  complete  the  operation  (Figs.  279 
and  280.) 

"When  the  neck  of  the  bladder  has  been  affected  so  that  inconti- 
nence of  urine  results,  obliteration  of  the  vagina  alone  is  not 
sufficient.  In  such  eases  it  has  been  proposed  to  make  the  rectum 
play  the  role  of  the  bladder.  Colpo-cleisis  is  also  necessai-y  then  to 
establish  a  recto-vaginal  fistula.  Baker  Brown  appears  to  have 
been  the  fii-st  to  perform  this  operation.  Eose  has  taken  up  this 
operation  imder  the  name  obhteratio  vulvse  rectaUs.  He  begins  by 
establisliing  an  ai-tificial  recto-vaginal  fistula  by  incising  the  recto- 
vaginal septum  and  carefully  coaptating  the  mucous  membranes. 
As  a   consequence  of  this  operation,  grave  accidents  have  been 


Cicatricial  Fistulce  of  the  Vagina.  527 

observed  that  are  due  to  the  passage  of  intestinal  gas  and  fecal 
material  into  the  vagina.  The  recto-vaginal  fistula  has  a  strong 
tendency  to  close.  Fritsch,  however,  has  observed  two  cases, 
operated  in  this  manner,  who  passed  urine  by  the  anus  without 
inconvenience. 


Fig.  275. — Very  extensive  vesico-yaginal  fistula  of  quadrangular  form, 
before  denudation. 

Cervical  fistula. — Urinary  fistulas  affecting  the  cervix,  may  be 
divided  into  two  distinct  classes.  One  of  these  includes  those 
openings  that  are  simply  in  juxtaposition  with  the  cervical  canal. 
These  have  been  called  vesico-utero-vaginal,  by  Jobert,  and  sub- 
divided into  superficial  and  deep,  according  as  the  destruction  of 
the  anter  or  lip  of  the  cer\dx  is  partial  or  completq.  This  nomen- 
clature is  defective;  I  shall  prefer  to  call  them  juxta-cervical, 
reserving  the  name  intra- cervical  for  perforations  that  have  been 
improperly  called  vesico-iiterine  fistulas. 

In  the  superficial  variety  of  juxta-cervical  fistulse  obliteration  is 
obtained  by  an  extensive  denudation  (Figs.  281,  282  and  283).  In 
the  deep  variety,  material  for  the- denudation  may  be  wholly  want- 
ing.    It  is  also  necessary  to  remember  that  denudation  of  the 


628  Cicatricial  Fistula  of  the  Vagina. 

stump  of  an  anterior  lip  that  is  almost  destroyed,  is  dangerous, 
because  of  the  contiguous  vesico-uterine  peritonseal  cul-de-sac, 
■which  has  been  di-awn  down  and  fixed  by  cicatricial  retraction. 
Deep  juxta-ceiTicalfistulse,  which  are  not  amenable  to  direct  suture, 
may  be  operated  in  a  different  manner ;  by  suturing  the  posterior 
lip  of  the  cei-rix  to  the  anterior  or  vaginal  lip  of  the  fistula  in  such 
a  manner  that  the  cei-rix  opens  into  the  bladder  (Fig.  284).  This 
is  called  vesical  hystero-cleisis  to  distinguish  it  from  hystero- 
stomato-cleisis,  where  the  hps  of  the  cervix  are  sutured  together 
(Fig.  286). 


Fig.  276  — Quadrangular  fistula,  after  denudation  and  suture. 

According  to  A.  ilartin,  intra-eervieal  fistulae  are  commoner  than 
has  been  generally  admitted,  but  that  they  have  a  natural  tendency 
to  spontaneous  closure,  when  they  are  not  too  extensive,  and  when 
they  do  not  compromise  the  ureter.  The  first  care  should  be 
dilatation  to  uncover  the  openmg.  If  the  orifice  is  narrow,  and 
there  is  a  fistulous  track  of  some  length,  the  galvano-cautery  may 
be  tried.  If  cauterization  fails,  there  remain  two  operations  to 
close  the  fistula  directly:  1.  Denudation  and  suture;  2.  Cysto- 
plasty.     The  method  of  denudation  and  suture  (Fig.  287)  has  been 


Cicatricial  Fistula  of  the  Vagina. 


529 


used  with  success  in  a  number  of  cases.  Cystoplasty  has  been  used 
successfully  where  the  fistula  is  very  high  up,  and  situated  on  the 
median  line.  FoUet  proceeds  as  follows :  He  first  dilates  the 
urethi-a  to  admit  the  finger;  the  cervix  is  drawn  down  to  the  vulva; 
the  anterior  cul-de-sac  is  incised,  and  the  bladder  detached  above 
the  perforation ;  this  organ  is  then  sutured  at  that  point.  As  a  last 
resort,  we  have  hystero-cleisis,  or  more  properly,  hystero-stomato- 
cleisis  (Fig.  236). 

Uretero-vaginal  or  uretero-cenical  fistulce  were  long  considered 
beyond  the  resources  of  art.  To-day,  several  procedures  are  appli- 
cable to  these  fistulse. 


Fig.  277 — Operation  for  vesico-vaginal  Fig.  278. — Operation  for  vesico-vaginal 
fistula  ty  flap-splitting  (Walcher).  a,  fistula  by  flap-splitting.  Schematic  figure 
fistula;  ^,  vesical  wall;   c.  vaginal  wall.         of  the  different  stages  (Walcher). 


1.  Direct  obliteration. — Simon's  procedure. — A  vesico-vaginal 
fistula  is  first  created  by  the  side  of  the  orifice  of  the  ureteral  fistula. 
Through  this  opening  a  sound  is  passed  into  the  urethra.  Then, 
still  operating  through  the  artificial  fistula,  the  ureter  is  slit  up  so 
as  to  transform  it  into  a  gutter,  to  an  extent  of  one  to  one  and  a 
half  centimetres.  The  edges  of  this  incision  are  separated  each 
day  with  a  sound  to  prevent  their  agglutination  and  to  cause  them 
to*  cicatrize  separately.  When  this  end  is  attained,  a  large  de- 
nudation is  made,  and  the  vesico-vaginal  fistula  is  closed  by  a 
transverse  suture. 

Landau's  method.— hsu-ida,}!  has  proposed  to  create  first  a  large 


530 


Cicatricial  Fistula  of  tlie  Vagina. 


vesico-vaginal  opening  by  the  excision  of  an  oval  section;  then 
he  passes  a  fine  elastic  sound  into  the  ureter.  The  patient  is 
afterward  placed  in  the  genu-pectoral  position  and  the  vaginal 
mucosa  denuded  all  around  the  fistula.  The  suture  is  in  a  dii'ection 
parallel  to  the  sound. 


Fig.  279. — Occlusion  of  the  vagina  or  colpocleisis ;  denudation  and  suture. 

Sckede's  method. — Schede  makes  a  vesico-vaginal  fistula  by  the 
excision  of  a  portion  of  the  bladder  two  centimetres  square  in  the 
direction  of  the  track  of  the  ureter.  Care  is  taken  to  sutui"e  the 
vesical  and  vaginal  mucous  membranes  of  the  Hps  of  the  excised 
portion  in  such  a  way  as  to  hem  the  opening  and  prevent  its  re- 
traction. An  elastic  sound  is  introduced  into  the  ureter  through 
the  artificial  opening,  pushed  into  the  bladder  and  out  thi-ough 
the  m-ethra.  After  this,  an  annular  denudation  is  made  around  the 
fistula,  preserving  a  zone  of  intact  mucosa  of  three  to  four  miUi- 
metres  wide  in  the  immediate  vicinity  of  the  opening.  In  this  way, 
after  suture,  the  edges  of  the  fistula  are  tui-ned  in  toward  the 
bladder  (Fig.  289). 


Cicatricial  Fistula  of  the  Vai/ina. 


531 


Flap -splitting. — Genu-pectoral  position,  transverse  incision  at  the 
fistula,  i)assing  beyond  each  side  to  the  extent  of  about  one  centi- 
metre ;  a  vertical  incision  at  each  extremity  gives  the  form  of  a 
letter  H  (M  reversed).  Dissection  of  the  edges  of  the  transverse 
incision  to  one  centimetre,  producing  two  small  flaps  by  sphtting 
the  septum.  The  two  flaps  are  drawn  toward  each  other  and 
coaptated  with  a  slight  effort.  They  are  carefully  sutured  with 
three  deep  stitches  and  three  superficial  stitches  of  silver  wu'e. 


Fig.  280. — Colpocleisis  (schematic  section). 


Fig.  281. — Juxtacervical  fistula;   denudation.     Fig.  282  — Juxtacervical  fistula;  suture. 

Gravity  of  the  operation. — Accidents. — Results. — I  shall  speak  in 
this  connection  only  of  the  direct  operation.  The  operation  is 
absolutely  benign.  There  is  some  slight  danger  only  when  the  fistula 
approaches  the  cervix  and  consequently  the  large  uterine  vessels, 
the  urethra  and  the  peritoufeum.     Verneuil  has  had  five  deaths  out 


532 


Cicatricial  Fistulce  of  ilie  Vagina. 


of  eighty  operations,  but  it  is  proper  to  note  that  the  majority  of 
these  date  back  to  a  period  prior  to  antisepsis.  To-day  this  pro- 
portion is  much  too  great.  Hegar  and  Kaltenbach  have  not  lost  a 
single  patient  out  of  a  series  of  more  than  eighty  cases. 


Fig.  283.  —  Superficial  juxtacervical 
fistula;  denudation  (schematic). 


Fig.   284.  —  Deep  juxtacervical   fistula; 
vesical  hysterocleisis  (schematic J. 


-Deep  juxtacervical  fistula.       Fig.  286. — Intra-cervical  fistula;  hystero- 
stomato-clesis  (schematic). 

Fatal  primary  haemorrhage  has  been  recorded.  Horteloup  has 
reported  an  example  due  to  the  wounding  of  a  very  large  uterine 
artery.     Secondary  haemorrhage  has  been  observed  from  the  third 


Cicatricial  Fistula  of  the  Vagina. 


533 


to  the  fifth  day,  but  I  believe  it  is  almost  always  due  to  a  fault  in 
the  operation. 

Injury  to  the  ureter,  especially  if  by  ligature,  is  announced  by 
the  appearance  of  lumbar  pains,  vomiting  and  fever. 


Fig.  287. — Operation  for  intra-cervical  urinary  fistula.     Sanger's  method. 

Septic  complications,  phlebitis,  pyemia,  lymphangitis  and  diph- 
theria, are  rare.  Peritonitis  may  be  the  result  of  an  injury  to  the 
peritonaeum  by  the  denudation,  or  by  the  sutures,  if  the  antiseptic 
precautions  have  been  defective. 

U 


Fig.  288. — Operation  for  uretei  \  1  il  li  1  il  i  Landiu  s  method.  U,  cervix;  Ur, 
ureter;  S,  vaginal  fold  corresponding  tu  the  mtei  ureteral  ligament;  F F,  vesico-vagi- 
nal  opening,  at  the  bottom  of  which  is  seen  a  sound  introduced  through  the  urethra. 

A  late  formation  of  calcareous  incrustations  in  the  bladder  about 
the  silver  wire  or  silk  thread  has  been  observed.  It  must  be  re- 
membered that  the  majority  of  women  affected  with  fistula  are  in 
a  favorable  condition  for  the  formation  of  calculi.  But  as  the 
calculi  are  phospbatic  they  can  easily  be  broken  and  removed. 

The  results  that  surgical  interference  yields  in  flstulce  is  remark- 
ably satisfactory.  It  could  almost  be  said  that  there  is  no  case 
which  cannot  be  cured  by  a  direct  or  an  indirect  operation. 


534 


Cicatricial  Fistulce  of  the  Vagina. 


Incontinence  of  urine  often  persists  long  after  the  cure  of  the 
fistula.  It  may  usually  be  explained  by  a  loss  of  tonicity  from  want 
of  use  of  the  vesical  sphincter.  Numerous  medical  procedures  have 
been  advised  for  this  infirmity ;  injections  of  strychnine,  hot 
douches,  electricity,  etc.  Small  plastic  operations  have  been 
attended  with  success.  Pawlix  removes  lateral  cuneiform  fragments 
of  tissue  to  contract  the  urethra  transversely  and  sutures  in  such  a 
way  as  to  positively  prevent  its  gaping.  He  commences  by  drawing 
the  urethral  canal  mth  a  hook  as  far  as  possible  to  one  side,  mark- 
ing the  points  which  correspond  to  this  displacement  (Fig.  291). 


Fig.  289. — Operation  for  uretero- vaginal 
fistula.    Schede's  method  (schematic). 


Fig.  290. — Operation  for  uretero- vagi- 
nal fistula;  flap-splitting  (schematic). 


He  obtains  the  extreme  limit  of  the  intended  denudation  and  makes 
two  incisions  from  above  downward.  These  incisions  incline  below 
in  such  a  way  as  to  permit  suture  of  the  urethra.  The  orifice  of 
the  lu'ethra  is  then  drawn  to  the  side  of  the  chtoris  and  the  point 
marked  to  which  it  can  be  carried.  The  incision  is  carried  to  this 
point,  gi^'ing  it  a  slightly  concave  du-ection  inward.  When  this 
tracing  is  finished  denudation  is  made,  hollowing  out  the  tissues  on 
each  side  of  the  urethra.  Quite  a  deep  wound  resists.  This  is 
sutured,  the  stitches  becoming  obhque  as  they  approach  the  ure- 
thi-al  orifice,  the  last  are  even  placed  dii'ectly  from  before  backward. 
Recto-vaginal  fistula. — ^Etiology. — The  most  fi-equent  cause 
is  parturition,  but  not  m  this  case  by  pressure  effects.  Eecto- 
vaginal  fistulas  are  a  more  immediate  consequence  of  traumatism, 
and  usuaUy  foUow  to  a  deep  laceration  of  the  periuieiim  which 
cicatrizes  below,  in  the  part  where  the  tissues  present  the  greatest 
thickness  while  a  perforation  remains  above.  Other  causes  may  be 
found,  more  rarely  :  tear  from  the  forceps  or  cephalotribe  gangrene 
of  the  septum  by  the  prolonged  arrest  of  the  head,  direct  trauma- 
tism by  a  foreign  body,  and  finally,  ulcerations  of  various  nature. 


Cicatricial  Fistulce  of  the  Vagina. 


535 


Pathological  anatomy. — I  shall  speak  only  of  fistulfe  that  may  be 
called  cicatricial,  leaving  out  of  consideration  recent  abnormal 
communications,  fresh  wounds,  or  cancerous  fistute.  They  should 
be  divided,  according  to  situation,  into  recto-vulvar,  inferior  recto- 
vaginal and  superior  recto-vaginal.  The  dimensions  are  variable ; 
recto-vulvar  fistulaB  and  fistulse  of  the  inferior  portion  of  the  vagina 
are  often  very  small.  Sometimes  they  are  markedly  labial  at  other 
times  they  have  an  oblique  track.  Fistulse  in  the  posterior  vaginal 
cul-de-sac  may  be  of  large  dimensions,  for  they  are  sometimes  the 
result  of  a  large  eschar.  The  edges  of  these  openings  are  usually 
hard,  callous  and  sharply  cut. 


Fig.  291. — Method  of  Pawlik  for  incontinence  of  urine.  I,  urethral  region  seen 
with  the  woman  in  the  genu-pectoral  position ;  II,  estimation  of  the  extent  of  denu- 
dation;  III,  denudation;   IV,  contraction  accomplished. 

Symptoms  and  diagnosis. — The  passage  of  gas  and  of  fecal  matter 
is  a  pathognomonic  symptom.  The  passage  of  fecal  matter  is  not 
absohitely  constant  and  is  wanting  when  the  fistula  is  oblique  and 
when  the  feces  are  solid,  appearing  with  diarrhoea.  The  orifice  may 
be  detected  by  the  finger  if  masked ;  it  is  always  possible  to  find  it 
with  the  speculum  and  probe.  If  necessary,  an  enema  of  milk  may 
be  used. 

Prognosis. — This  is  a  very  obstinate  affection,  however  small  it 


536  Cicatricial  Fistulce  of  the  Vagina. 

may  be  in  appearance,  for  the  difficulty  of  repairs  bears  no  relation 
to  the  extent  of  the  lesion.  The  most  difficult  cases  are  those  in 
which  there  are  multiple  cicatrices  in  the  vagina. 

Treatment. — In  very  small  iistulse,  especially  if  there  is  a  long 
fistulous  track,  cauterization  may  be  attempted.  For  perforations 
of  some  extent,  the  only  resource  is  denudation  and  suture. 
Obstacles  to  success  are  greater  than  in  case  of  urinary  fistulae,  the 
principal  one  being  the  infection  of  the  wound  by  gas  and  fecal 
material.  It  is  only  by  a  very  large  and  very  exact  coaptation  that 
success  is  possible.  Three  ways  are  open  to  the  surgeon :  First,  the 
vagina ;  second,  the  rectum ;  third,  the  perinseum. 

1.  Operation  through  the  vagina. — This  procedure  may  be  at- 
tempted first,  especially  in  fistulse  not  complicated  by  cicatrices 
that  make  the  vagina  unyielding.  A  preliminary  treatment  is 
necessary  to  prepare  the  patient  for  this  operation,  repeated  pur- 
gatives, enemas,  light  diet,  perfect  antisepsis  of  the  vagina  and 
rectum.  Intestinal  antisepsis  maybe  supplemented  by  the  admin- 
istration of  naphthol.  The  patient  is  placed  in  the  dorso-sacral 
position,  the  vagina  is  opened  by  lifting  the  anterior  wall  with  a 
speculum  and  by  the  use  of  lateral  retractors,  the  borders  of  the  fistula 
are  fixed  with  bullet  forceps.  The  recto-vaginal  septum  may  be  up- 
lifted by  the  finger  of  an  assistant  or  by  packing  the  rectum  with 
iodoform  gauze.  The  denudation  is  made  very  deep.  The  sutures 
are  passed  under  the  entire  extent  of  the  wound,  except  the  rectal 
mucous  membrane.  Some  superficial  sutures  are  then  placed,  in- 
cluding only  the  vaginal  mucosa  and  alternating  with  the  preceding. 
These  are  tied  first  and  then  the  deep  sutures.  Silver  wii'e  is  best 
as  it  more  surely  remains  aseptic.  The  hue  of  suture  is  disposed 
in  the  du-ection  where  there  will  be  the  least  dragging,  for  large 
perforations  this  is  usuaUy  in  the  transverse  dii-ection. 

2.  Operation  through  the  rectum. — The  patient  is  placed  in  the 
genu-pectoral  or  in  Sims'  position.  A  forcible  dilatation  of  the 
anal  sphincter  is  first  made.  The  rectal  cavity  is  exposed  with  a 
short  speculum  and  with  retractors.  The  borders  of  the  fistula  are 
drawn  tense  and  fixed  ■nith  forceps  and  hooks.  Continuous  irrigation 
■nill  be  of  material  service.  The  sutures  are  passed  as  follows : 
The  needle  is  made  to  enter  close  to  the  rectal  side  of  the  wound, 
and  is  carried  toward  the  vagina  so  as  to  enter  this  canal  about  half 
a  centimetre  fi-om  the  edge  of  the  denuded  surface.  However,  it 
may  be  easier  in  some  cases  to  place  the  sutures  thi-ough  the 
vagina.  Especial  care  should  be  taken  to  avoid  the  interposition 
of  the  rectal  mucous  membrane  in  the  wound. 

Peiinteal  operation. — It  is  necessary  to  distinguish  two  kinds  of 
cases,  one  in  wliich  the  peruiieum  is  intact,  the  other  in  which  it  has 
been  lacerated  and  has  imperfectly  united.  In  case  of  an  intact 
perinaeum,  its  thickness  and  its  resistance  may  be  one  of  the  causes 


Cicatricial  Fistulce  of  the  Vagina.  537 

of  the  difficulties  in  closing  the  fistula  through  the  vagina.  The 
fistulous  tract  should  be  dissected  with  care,  removing  all  cicatricial 
tissue,  and  the  suture  made  immediately,  according  to  one  of  the 
procedures  which  will  be  explained  in  the  discussion  of  lacerated 
perinseum.  In  cases  of  lacerated  perinseum,  this  operation  should 
be  done  at  the  same  time  with  that  of  the  principal  injury.  Lawson 
Tait's  method  of  flap-splitting  deserves  the  first  trial. 

After-treatment. — Should  the  bowels  be  confined,  some  authors 
administer  opium  for  ten  to  twelve  days.  Other  surgeons  prefer  to 
keep  the  bowels  open.  Hegar  recommends  the  following:  The 
patient  is  actively  purged  before  the  operation,  and  only  milk  and 
soups  are  given  for  the  first  three  days  thereafter.  The  evening  of 
the  fourth  day  he  gives  a  small  dose  of  calomel,  and  the  following 
morning  a  glass  of  a  purgative  mineral  water.  After  the  second 
stool,  a  little  opium  prevents  evacuation.  Stools  are  thus  induced 
every  forty-eight  hours.  The  metallic  sutures  are  left  in  place 
fifteen  days.  Silk  sutures  become  infected  at  the  end  of  eight 
days,  and  cannot  be  left  longer  without  causing  inflammation. 

Entero-vaginal  fistulce. — Thus  are  designated  fistulous  commu- 
nications between  the  vagina  and  some  portion  of  the  intestines 
other  than  the  rectum. 

JEtiology. — In  the  great  majority  of  cases  the  origin  of  the  lesion 
is  in  a  laceration  of  the  posterior  cul-de-sac  of  the  vagina  during 
delivery.  An  intestinal  loop  prolapses  tln-ough  the  perforation,  be- 
comes adherent  and  gangrenous.  Direct  traumatism  is  a  rare 
cause.  The  suppuration  of  a  dermoid  cyst  or  of  an  extra-uterine 
pregnancy,  opening  both  into  the  intestine  and  the  vagina,  are  ex- 
ceptional causes.  The  perforations  of  cancer  do  not  come  under 
consideration  here. 

Pathological  anatomy. — The  posterior  cul-de-sac  of  the  vagina  is 
almost  the  exclusive  seat  of  the  abdominal  opening.  Bretzmann 
and  Dalilmann  have  seen  a  fistula  opening  into  the  anterior  cul-de- 
sac.  The  portion  of  the  intestine  that  is  most  frequently  afl'ected 
is  the  last  portion  of  the  ilium.  The  orifice  is  very  large  when  the 
whole  of  the  intestinal  loop  has  sloughed  away.  Sometimes  it  is 
double.  There  may  be  cicatricial  bands  of  the  vagina  in  its 
vicinity.  The  cervix  is  affected  with  an  inflammation  caused  by 
the  constant  infection  of  the  vagina,  which  is  itself  inflamed. 

Symptoms. — When  the  communication  is  very  large  the  major 
part  or  the  whole  of  the  feces  may  pass  into  the  vagina.  The 
opening  can  easily  be  discovered  with  the  aid  of  the  speculum, 
putting  the  patient  in  difl^erent  positions  successively. 

Diagnosis. — The  portion  of  the  intestine  which  is  the  seat  of  the 
perforation,  wiU  be  suspected  from  the  character  of  the  material 
that  passes  the  orifice.  Feces  from  the  'small  intestine  are  liquid, 
greenish  or  yellowish.     The  stools  appear  two  or  three  hours  after 


53.8  Cicatricial  Fistulce  of  the  Vagina. 

a  meal,  if  the  opening  is  at  the  terminal  portion  of  the  ilium,  and 
they  occur  earher  as  the  intestinal  opening  is  higher  up.  They 
follow  later,  and  have  a  more  solid  consistence,  a  fecal  appearance, 
if  the  perforation  is  situated  in  the  sigmoid  flexure. 

Treatment. — If  the  fistulous  opening  is  very  small,  cauterization 
is  first  attempted,  but,  in  case  of  failure  of  this  procedure,  denu- 
dation and  suture  will  be  necessary.  The  situation  is  very 
different  when  the  perforation  of  the  intestine  is  terminal  and  the 
whole  of  the  feces  pass  into  the  vagina.  The  continuity  of  the 
digestive  tube  must  first  be  estabhshed,  transforming  the  vaginal 
aims  into  an  entero- vaginal  fistula,  with  final  obliteration  by  denu- 
dation and  suture.  When  success  is  impossible  by  this  method, 
I  believe  it  becomes  legitimate  to  perform  laparotomy  and  detach 
the  intestinal  ends  from  the  vaginal  cul-de-sac,  afterward  resecting 
this  portion  of  the  intestine  and  suturing  the  ends  together.  This 
operation  is  the  only  rational  one  for  entero-uterine  fistula.  If  the 
end  of  the  lower  segment  of  the  intestine  is  notably  contracted, 
the  upper  segment  should  be  opened  into  the  nearest  part  of  the 
large  intestine. 

Colpocleisis,  or  obliteration  of  the  vagina  below  the  fistula,  after 
making  a  large  communication  between  the  rectum  and  the  vagina, 
has  been  advised  by  Simon.  It  would  be  permissible  only  after 
obUteration  of  the  uterus  by  anhystero-stomato-cleisis.  Casamayor's 
operation  is  preferable ;  it  consists  in  making  a  passage  for  the 
derivation  of  the  feces  toward  the  rectum.  He  introduces  one  jaw 
of  a  long  curved  forceps  into  the  intestines  thi-ough  the  fistula,  the 
other  branch  is  introduced  into  the  rectum.  They  are  then  brought 
together,  after  being  sure  that  they  comprise  notliing  but  the  walls 
that  it  is  intended  to  divide.  An  eschar  is  thus  obtained,  and  after 
it  sloughs  out,  the  feces  can  pass  diiectly  into  the  rectum.  Verneuil 
proposed  the  following  modification  of  Casamayor's  operation :  1. 
The  use  of  a  curved  trocar  to  perforate  the  recto-vaginal  septum  at 
one  centimetre  below  the  fistula,  then  to  pass  a  rubber  tube  ;  2.  To 
perforate  the  ileo-reetal  septum  in  the  same  maimer,  at  about  three 
centimetres  above  the  first  puncture,  and  to  pass  another  rubber 
tube ;  3.  To  tie  the  two  rectal  ends,  thus  obtaining  a  loop  with  two 
vaginal  ends  which  have  only  to  be  tied  and  the  rubber  ligature  left 
to  accomplish  the  ilivisiou  of  the  torsion  by  its  elasticity. 


Vaqinismus.  539 


CHAPTER  XLI. 


VAGINISMUS. 

Vaginismus  consists  in  an  abnormal  hyj)er8esthesia  of  the  external 
genitals,  causing  spasmodic  contraction  of  the  vaginal  constrictor, 
and  even  of  the  other  muscles  of  the  pelvic  floor.  Three  distinct 
types  exist:  1.  Hyperassthesia  with  contraction.  2.  Hyperjesthesia 
without  contraction.  3.  Contraction  without  hypersesthesia.  The 
first  of  these  types  is  much  the  most  frequent,  and  the  last  the 
most  rare.  A  classification  based  on  the  seat  of  the  contraction 
has  been  proposed,  thus  distinguishing  an  inferior  vaginismus  from 
a  superior  vaginismus.  This  distinction,  I  tliink,  does  not  deserve 
recognition,  for  contraction  of  the  deep  part  of  the  canal  is  quite 
an  exceptional  variety.  With  regard  to  essential  or  idiopathic 
vaginismus,  it  probably  does  not  exist ;  the  point  of  departure  of 
the  reflex  has  not  been  recognized  in  these  cases. 

Etiology;  pathogeny. — Two  conditions  are  necessary  for  the  oc- 
currence of  vaginismus :  1.  A  great  nervous  irritability  on  the 
part  of  the  patient.  2.  An  irritation  of  the  external  genital  organs 
giving  rise  to  exaggerated  reflexes  of  the  sensory  and  motor  nerves, 
producing  hyperfesthesia  and  contraction.  The  majority  of  patients 
affected  with  vaginismus  are  young,  nervous,  sometimes  hysterical; 
but  it  should  not  be  concluded  that  hysteria  is  an  absolute  requisite, 
and  that  without  it  vaginismus  could  not  exist.  The  irritation  of 
the  genital  organs  has  its  origin  most  frequently  at  the  beginning 
of  conjugal  life,  in  the  attempts  at  defloration. 

Sclu'oeder  noted  the  importance  of  the  situation  of  the  vulva  in 
some  women,  where  it  is  placed  forward  in  such  a  manner  that  the 
urethral  orific6  and  the  fossa  navicularis  are  forced  against  the 
symphysis  in  the  first  attempts  at  coitus.  Excoriations  result  with 
such  hyperaesthesia  that  the  slightest  contact  is  painful.  In  other 
women  the  hymen  possesses  an  unusual  firmness ;  again,  its  orifice 
may  be  large  enough  to  admit  the  penis  without  rupture.  In  both 
cases  the  hymen  may  be  inflamed  and  very  sensitive.  The  lack  of 
rigidity  of  the  male  organ  may  also  be  a  cause  of  vaginismus  by 
preventing  rupture  of  the  hymen.  Vaginismus  is  also  observed  in 
women  completely  deflorated,  from  inflammation  of  the  carunculae 
myrtiformes. 

Small  polypoid  tumors  of  the  urethra  and  hernias  of  the  urethral 
mucosa,  irritated  by  coitus,  produce  the  same  effect.     Fissure  of 


540  Vaginismus. 

the  anus  also  induces  sometimes  a  vaginal  sphincter algia.  Finally, 
it  has  been  suggested  that  uterine  affections  and  especially  ulcer- 
ations of  the  cervix  may  have  the  same  result.  I  believe  that  this 
is  an  abuse  of  language  and  that  the  term  vaginismus  has  been 
wrongly  applied  to  simple  painful  phenomena  without  true  hj-per- 
sesthesia  and  their  consequences. 

AU  the  preceding  facts  pertain  to  vaginismus  of  the  most  frequent 
type,  or  to  hyperesthesia  accomi^anied  with  contraction.  In  much 
rarer  cases  the  latter  may  be  wanting.  This  is  particularly  observed 
among  yoimg  girls  who  have  never  submitted  to  coitus,  but  who 
are  not  beyond  the  suspicion  of  onanism. 

Pathological  anatomy. — The  lesions  are  not  in  proportion  to  the 
symptoms.  Most  frequently,  there  are  found  signs  of  inflammation 
about  the  vulvar  orifice,  of  the  hymen  or  its  remains,  fissm-es, 
rhagades  of  the  vulvar  or  anal  orifice,  polypi  or  vascular  tumors  of 
the  urethi-a.  Dilatation  of  the  ui-ethi-a  is  found  where  there  have 
been  attempts  at  heterotopic  coitus. 

Diagnosis. — Vaginismus  should  not  be  confomided  with  simple 
pain  during  coitus.  Imperforation  of  the  hymen  and  atresia  of  the 
vagina  will  be  immediately  recognized  by  insi^ection.  In  this  case 
there  wiU  be  absence  or  the  retention  of  the  menses. 

Treatment. — The  object  of  treatment  is  to  diminish  the  morbid  hy- 
perffisthesia  and  to  destroy  the  lesion  which  called  it  into  play.  All 
sexual  relations  should  be  forbidden,  kn  anti-spasmodic  treatment 
should  be  instituted ;  hydi-otherapy  and  bromide  of  potassium  will  be 
of  especial  service.  To  this  may  be  added  cocaine,  belladomia  and 
opium,  locally.  But  the  chief  indication  is  to  remove  the  local  cause 
which  is  the  origin  of  the  reflexes.  The  ^-ulvitis  must  be  cured  and  the 
contiguous  lesions  attacked.  If  there  exists  an  anal  fistula,  dilatation 
should  be  employed.  If  there  is  a  polypus  of  the  urethra,  it  should  be 
excised.  Excision  of  a  thick,  inflamed  hymen  or  of  the  carunculae 
myrtiformes  often  relieves  the  trouble.  If  attempts  at  coitus  still 
remain  painful,  a  forced  dilatation  may  be  resorted  to  under 
anaesthesia.  I  will  only  mention  the  use  of  electricity  which  has 
been  attended  with  some  success.  The  patients  being  generally 
very  antemic  a  tonic  treatment  should  not  be  neglected.  Finally, 
careful  attention  should  be  given  to  the  mental  condition  of  some 
patients,  especially  those  predisposed  to  mania  by  heredity.  In  such 
cases,  moral  measures,  change  of  scene,  sea  voyages  should  be 
advised. 


Laceration  of  the  Permcemn.  541 


CHAPTER  XLII. 


LACERATION   OF   THE   PARIN^UM. 

Etiology;  Pathogeny. — -At  the  moment  of  delivery  the  vulva  gives 
passage  to  the  foetus,  a  body  of  excessive  dimensions  in  comparison 
with  the  orifice  it  traverses.  Two  conditions  are  essential  to  the 
passage  of  the  foetus  without  perinseal  lacerations:  the  imbibition 
of  all  the  soft  parts,  in  consequence  of  the  intense  venous  congestion 
at  the  end  of  pregnancy ;  the  elasticity  of  the  muscular  and  cutane- 
ous planes.  When  one  of  these  normal  conditions  is  wanting  the 
perinseum  gives  way  or  is  ruptured.  This  accident  occurs  in 
exceptional  rigidity  of  the  tissues  in  women  becoming  mothers  at 
an  advanced  age  or  presenting  a  special  narrowness  of  the  vulva; 
excessive  size  of  the  head,  or  an  unreduced  occipito-posterior  po- 
sition ;  too  sudden  passage  of  the  head  and  shoulders ;  narrowness 
of  the  pubic  arch ;  pelvis  deformed  by  too  perpendicular  a  position 
of  the  sacrum  permitting  the  head  to  be  carried  too  far  backward, 
as  in  a  flat  or  rachitic  pelvis ;  faulty  use  of  the  forceps ;  over-rapid 
version,  etc. 

Dkect  violence  is  also  a  cause  of  perinasal  injuries,  but  compara- 
tively a  rare  one. 

Pathological  anatomy. — The  following  description  applies  only  to 
old,  cicatrized  lacerations.  It  is  at  the  fourchette,  at  a  little  to  one 
side  of  the  median  hue,  that  the  laceration  occurs.  It  is  incomplete 
when  it  goes  only  to  the  anus,  complete  when  it  includes  it.  In  in- 
complete lacerations  two  varieties  may  also  be  distinguished, 
according  as  the  fourchette  alone  is  involved  or  as  the  tear  is  deeper 
and  comprises  the  muscular  planes,  with  the  exception  of  the 
sphincter  ani.  The  vulva  appears  elongated  posteriorly  and  gaping. 
At  the  fourchette  a  smooth  cicatricial  surface  is  found.  If  the 
lesion  is  of  some  standing  there  is  almost  always  a  slight  cystocele 
and  even  prolapse  of  the  uterus. 

In  complete  laceration,  the  vulvar  and  anal  orifices  are  one  aixl 
form  an  opening  into  which  folds  of  the  rectal  mucosa  often  pro- 
ject. The  recto- vaginal  septum  is  semicircular  in  form  or  rounded. 
The  summit  of  the  curve  is  sometimes  detached  in  a  small  tri- 
angular flap.  The  posterior  column  of  the  vagina  is  sometimes 
isolated  by  two  lateral  tears  presenting  the  appearance  of  a  ii^aila. 
Cicatricial  tissue  deforms  this  region  also  in  a  variable  manner  (Fig. 
292).  Two  varieties  have  been  distinguished  in  complete  laceration, 
according  as  the  spliincter  and  the  anal  orifice  are  torn,  or  as  the 


542 


Laceration  of  the  Perincevm. 


division  extends  to  the  recto- vaginal  septum.  This  distinction  is  of 
some  imi)ortance  in  an  operative  point  of  view  for  the  repair  of  the 
septum  necessitates  an  additional  step. 


Fig.  292. — Complete  laceration  of  the  perinasum  and  of  a  portion  of  the  recto-vagina. 

Symptoms.^— Digital  examination  and  inspection  reveal  the  con- 
ditions I  have  pointed  out. 

Prognosis. — This  lesion  is  very  troublesome,  even  when  the  tear 
does  not  give  rise  to  the  infirmity  which  results  from  the  abolition 
of  the  anal  sphincter.  It  predisposes  to  genital  prolapsus  and  to 
metritis. 

Treatment. — Beccnt  lacerations. — Permseal  injm'ies  should  be  re- 
paired immediately  after  their  occurrence  whenever  it  is  possible. 
The  simplest  and  most  expeditious  method  of  operation  is  by  suture 
in  superposed  rows.  The  patient's  hmbs  are  kept  close  together 
and  she  is  kept  in  bed  for  fifteen  days.  Great  care  must  be  taken 
in  the  cleanliness  of  the  parts,  bathing  ^nth  subhmate  solution  and 
powdering  with  iodoform. 

Clcatrhcd  lacerations  of  the  perinceum. — Incomplete  lacerations. — 
All  the  procedures  for  colpoperiueorraphy  that  I  have  described  iu 
the  chapter  on  genital  prolapsus  find  application  here.     There  is 


Laceration  of  the  Perinceum. 


543 


only  a  difference  of  degree  between  relaxation  of  the  perinseum  and 
incomplete  lacerations.  I  shall  not  return  to  the  methods  I  have 
described,  the  colpoperineorraphy  of  Hegar,  the  perineanxesis  of 
A.  Martin,  the  perineoplasty  of  Doleris,  etc.  I  shaU  confine  my- 
self to  giving,  without  description,  the  illustration  of  Simon's  method 
for  incomplete  laceration  (Fig.  293). 


Fig.  293.- 


-Incompbte  laceration  of  the  perinasum.     Perineorrhaphy. 
Simon's  method. 


Emmet's  method. — His  procedure  for  incomplete  lacerations  should 
not  be  confounded  with  his  methed  for  complete  laceration,  as  it  is 
essentially  different.  This  surgeon  removes  from  the  periuEeum 
and  from  the  internal  and  inferior  part  of  the  vulva  a  mucous  flap 
in  the  form  of  two  leaflets  (Fig.  294).  The  inferior  portion  of  the 
posterior  vaginal  wall  is  also  denuded.  In  suturing,  the  tkread  C 
(Fig.  295)  wliich  passes  into  the  labium  above  the  denudation  j)ene- 
trates  into  the  posterior  vagmal  wall  C  which  has  not  been  denuded. 
The  thread  D  passes  under  all  the  superior  portion  of  the  denu- 
dation of  the  labium,  then  into  the  denuded  portion  of  the  vagina, 
but  only  on  the  median  line,  and  is  free  to  all  the  rest  of  its  extent. 
On  the  contrary,  the  threads  1,  2,  3  and  4  encircle  the  depth  of  the 
lip  and  of  the  septum.  When  these  sutures  are  tied  the  result  is 
that  the  right  part  of  the  median  vaginal  leaflet  (Fig.  294)  is  placed 


544 


Laceration  of  the  Perinceum. 


in  contact  with  the  deepest  part  (2)  of  the  denuded  leaflet  of  the 
right  labium.  The  left  vaginal  part  (4)  is  appHed  to  the  posterior 
part  of  the  left  labial  leaflet  (5).  The  external  parts  of  the  right 
and  left  labial  leaflets  (1  and  6)  come  together  to  reconstruct  the 
perinseum  and  the  fourchette. 


Fig.  294. — Incomplete  laceration.    Perineorrhaphy.   Emmet's  method  (schematic). 


Fig.  295. — Incomplete  laceration.     Perineorrhaphy.     Emmet's  method. 

Lawson  Tait's  method  {for  incomplete  lacerations. — I  shall  foUow 
Sanger's  description.  Sanger  advises  introducii'.g  into  the  rectum 
a  tampon  of  cotton,  a  sponge,  or  a  tampon  of  iodoform  gauze 
smeared  with  vaseline.  In  this  way  the  posterior  wall  of  the  vagina 
is  pushed  forward.  Two  fingers  are  placed  in  the  rectum  while  an 
assistant  makes  the  operative  field  as  tense  as  possible  bj^  carrying 
the  sides  of  the  mlxa  outward.  The  posterior  waU  of  the  vagina  is 
then  visible  to  a  great  extent.  The  point  of  the  scissors  is  pushed 
in  the  median  line,  from  before  backward,  between  the  posterior 
commissure  of  the-\-ulva  and  the  anus,  and  the  recto-vaginal  septum 
is  split  first  to  the  right  and  then  to  the  left  after  ha^-ing  turned 
the  scissors  on  themselves  (Fig.  296).  At  the  extremities  of  this 
transverse  section  two  vertical  incisions  are  made  from  the  union 


Laceration  of  the  PerincEum. 


545 


of  the  labia  majora  and  minora  down  to  meet  the  incision  made  by 
the  scissors.  These  two  vertical  incisions  may  be  made  with  the 
scissors  by  going  from  below  upward.  The  liberated  vaginal  flap 
soon  curls  on  itself  (ah)  by  virtue  of  its  elasticity  (Fig.  297)  and 
then  covers  only  part  of  the  denudations.  This  wound  from  denu- 
dation has  a  quadrilateral  form  with  blunt  angles  {ad eh)  and  is 
surrounded  by  skin  on  thi-ee  sides.  The  surface  of  denudation  is 
smoothed  by  trimming  with  the  scissors.  When  the  perinseum  has 
not  been  transformed  into  cicatricial  tissue,  the  flow  of  blood  is 
quite  free,  but  is  venous.  When  arterioles  are  encountered  forci- 
pressure  is  sufficient  to  control  them. 


Fig.  296. — Incomplete  laceration.     IVnneorrhaphy.     La wson  Tail's  method. 


The  left  index  and  middle  fingers  are  placed  in  the  rectum  as 
a  guide  during  the  application  of  the  sutures.  The  needle  enters 
the  wound  itself  just  within  the  left  border,  then  passes  transversely 
through  the  tissues  and  out  at  a  corresponding  point  just  within 
the  right  border,  the  skin  is  not  involved  (Fig.  298).     A  silver  wire 


546 


Laceration  of  the  Perirueum, 


Fig.  297. — Incomplete  laceration.     Perineorrhaphy.     Lawson  Tail's  method. 


Fig.  29S. — Incomplete  laceration.     Lawson  Tait's  method;  suture. 

is  introduced  into  the  eye  of  the  needle  and  it  is  -withdrawn.  Four 
sutures  are  sufficient.  The  sutures  are  tied  (Fig.  299)  between  the 
lips  of  the  wound,  after  carefully  hathing  -n-ith  a  sublimate  solution, 
and  the  tampon  is  withdrawn  from  the  rectum.     The  edges  of  the 


Laceration  of  the  Perinmiim. 


Sil 


wound  are  brought  together.  The  line  of  suture  is  not  perfectly 
rectilinear  because  the  silver  wire  sutures  emerge  through  the  lips 
of  the  wound,  but  between  them  the  contact  is  perfect.  Toward 
the  anus  there  often  remains  a  fold  which  corresponds  to  the  inferior 
transverse  edge  of  the  denudation.  The  liberated  mucous  flap 
forms  a  fold  open  in  front  or  a  little  rosette.  Lawson  Tait  does 
not  use  the  superficial  sutures.     Sanger  advises  them. 


FiGi  299. — Incomplete  laceration.     Tait-Sanger  method;  suture. 


Fig.  300. — Complete  laceration.    Simon-       Fig.  301. — Complete  laceration  of  the 
Hegar  method;   denudation.  perinajum.     Simon-Hegar  method;  vagi- 

nal and  rectal  sutures. 

The  post-operative  dressing  consists  in  insufflations  of  iodoform, 
the  use  of  iodoform  gauze  or  subhmated  cotton,  to  surround  the 
ends  of  the  silver  wire.  During  the  first  three  days  catheterization 
shoiild  be  employed.  The  seventh  day  the  superficial  stitches  are 
removed  and  on  the  fourteenth  the  deep  sutures.  The  patient  can 
then  be  allowed  up.     Martin  has  modified  the  suture  very  advan- 


548 


Laceration  of  the  Perincewm. 


tageously.  In  the  place  of  the  interrapted  suture,  be  employs 
jumper  catgut  and  the  continued  suture  in  superposed  tiers.  The 
operation  is  thus  more  rapid  and  the  coaptation  perfect. 


Fig.  302. — Complete  laceration.     Simon-Hegar  method.     General  disposition 
of  the  sutures. 

Complete  lacerations  of  the  perinmum. — The  triangular  denudation, 
introduced  by  Simon,  has  been  adopted  and  perfected  by  Hegar. 
The  various  stages  of  the  Simon-Hegar  operation  are  as  follows : 

First  stage. — Denudation.  —  To  bare  the  operatiye  field  an 
assistant  lifts  the  anterior  vaginal  wall  with  a  speculum  while  the 
surgeon  seizes  and  fixes  with  the  forceps  the  posterior  vaginal  wall 
above  the  point  x  (Fig.  300).  The  skin  is  then  seized  with  the 
forceps  at  the  points  corresponding  to  the  extremities  of  the  new 
perinseum,  that  is,  in  front  at  a  and  /),  behind  at  c  and  d.  The  denu- 
dation is  commenced  by  marking  out  the  triangle  nxn.  The 
point  .r  should  be  situated  on  the  median  line  of  the  posterior 
vaginal  waU  and  about  two  centimetres  distant  from  the  point  e 
■which  represents  the  extremity  of  the  triangle  of  the  denudation  of 


Laceration  of  the  Perinceum. 


549 


the  rectal  wall.  From  nn  a  curved  incision  is  carried  upward  and 
outward.  It  extends  to  the  points  a  and  b,  which  by  uniting  form 
the  fourchette.  These  points  are  situated  on  the  inferior  part  of 
the  internal  borders  of  the  labia  majora.  From  here  the  incisions 
a  c  and  b  d  are  traced,  which  when  united  form  the  raphe  of  the  new 
perinseum.  These  incisions  will  converge  toward  the  anus  and  are 
then  inflected  to  trace  the  lines  ce  and  ed.  The  edges  of  the  flap 
thus  marked  out  are  isolated  and  the  denudation  is  finaUy  completed 
by  completely  dissecting  the  circumscribed  flap.  The  bleeding 
points  are  compressed  with  a  tampon  of  cotton  and,  if  necessary, 
are  seized  momentarily  with  the  forceps. 


Fig.  303. — Complete  laceration.     Freund's  method. 

Second  stage. — Suture. — When  the  wound  has  been  well 
smoothed,  the  triangle  nxn  (Fig.  301)  is  first  sutured.  As  soon  as 
the  vaginal  suture  is  complete  some  stitches  are  passed  in  the 
rectum.  Hegar  uses  for  the  rectal  suture  catgut  or  very  fine  silk. 
There  are  two  different  methods  of  tying  the  threads  :  1.  To  place 
all  the  thi'eads  first  and  then  tie  them,  as  in  Hildebrandt's  method, 
as  wUl  be  seen  later.     2.  To  place  the  deepest  tlu'ead  first,  to  draw 


550 


Laceration  of  the  Perinceum. 


it  tight  and  tie  it,  noting  the  result ;  to  place  a  second  suture  in- 
cluding more  tissue,  to  tighten  and  tie  it;  continuing  thus  equal- 
izing the  Ui3S  of  the  wound  by  modifying  the  disposition  of  the 
threads,  correcting  the  denudation  as  required.  This  last  procedure 
is  now  followed  by  Hegar.  As  soon  as  the  rectal  and  vaginal  sutures 
are  applied  and  secured,  the  perinteal  stitches  are  introduced  (Fig. 
302).  The  ordinary  rules  are  followed  here.  "VNTiile  tjing  the 
sutures  the  patient's  legs  should  be  brought  together  to  diminish 
the  tension.  When  the  suturing  is  done,  care  is  taken  to  express 
with  the  fingers  the  little  blood  that  may  be  retained  between  the 
lips  of  the  wound  and  the  vagina  is  carefully  cleansed  with  an  anti- 
septic douche,  as  also  are  the  rectum  and  the  perineal  wound. 


c 

s^ 

y 

\ 

t-^P. 

y 

^ 

V 

iJ^'T  ;     1 

'   rvLj 

/fl\ 

f  i 

/ 

N 

:i-^ 

*Ci ;  ; 

J  / 

\ ' 

•  '  i  ;> 

N:  i 

■  / 

V; 

'  i  \J/. 

Fig.  304. — Complete  laceration.     Hildebrandt's  method. 

Freund's  method. — Freund  has  strenuortsly  insisted  on  the  neces- 
sity of  making  denudation  in  such  a  manner  that  the  condition  is 
reproduced  in  which  the  perineum  is  found  immediately  after  the 
laceration  occurs.  He  argues  that  in  denudation  by  the  usual 
method  parts  are  sutured  together  which  do  not  natui-ally  lie  one 
against  the  other.  Instead  of  this,  Freund  makes  a  denudation  to 
which  he  gives  a  form  completely  subordinate  to  that  of  the  tear. 
For  example,  there  is  the  cicatrix  ha^•ing  the  form  00  (Fig.  303,  1). 
It  is  the  remains  of  a  tear  which  has  retracted.  The  denudation 
reproduces  this  form.  It  is  figured  by  the  lino  hah.  Freund  then 
incises  the  posterior  column  of  the  vagina,  at  some  distance  from 


Laceration  of  the  Perinceum. 


551 


its  extremity ;  on  the  sides  of  this  column  lie  carries  the  knife  behind 
toward  the  points  b  h  (Fig.  303,  2)  to  circumscribe  the  cicatrices 
on  the  vaginal  wall,  on  to. the  labia  majora.  He  completes  the 
operation  ui  the  usual  way.  The  line  xy  (Fig.  303,  3),  which  corre- 
sponds to  the  rectum,  is  sutured.  Each  border  of  the  posterior  vagi- 
nal column  is  united  to  the  external  lip  of  the  denuded  surface  that 
has  been  designed  on  the  lateral  portions  of  the  posterior  vaginal 
wall.  The  wounds  o^j  and  qp  (Fig.  303,  3)  are  sutured.  There  only 
remain  to  be  sutured  the  lips  of  the  wound  p  r  and  p  z,  which  form 
by  their  union  the  internal  portion  of  the  vulva,  and  the  lines  ry 
and  zy  which  constitute  the  perineum  (Fig.  303,  4). 


Fig.  305. — Complete  laceration.      Hildebrandt's  method,     u,  uterus;    a,  rectum;  . 
b,  vagina;  c,  perinaeum.     Disposition  of  the  sutures. 

Hildebrandt's  method. — A  denudation  is  designed  which  has  a  form 
analogous  to  a  clover  leaf  and  which  makes,  at  least  for  a  part  of 
the  surface,  a  perineorrhaphy  with  sutures  tied  on  a  single  side. 
He  first  places  the  vaginal  sutures,  then  the  rectal.  But  for  the 
remainder  of  the  peringeo-vaginal  wound  he  applies  only  very  deep 
sutures  that  are  tied  on  the  perinseum  (Figs.  304  and  805). 

Heppner  follows  the  same  indications  in  proposing  the  figure  of 
eight  suture.  The  suture  is  threaded  into  a  needle  at  each  end.  Each 
of  these  needles  is  entered  in  the  vaginal  lip  of  the  wound,  issues  at 
the  middle  of  the  wound  and  penetrates  into  the  opposite  side  by 
crossing  with  the  other  needle  (Fig.  306). 

Lauenstein's  method  (suture). — The  object  of  this  method  of  sub- 
mucous suture  is  to  prevent  infection  of  the  suture  tracks.  Lau- 
enstein  introduces  the  sutures  at  a  half  centimetre  from  the  edges 


552 


Laceration  of  the  Perinmtm. 


of  the  wound  iu  the  denuded  surface  and  makes  an  interrupted, 
buried  suture.  When  the  rectal  and  vaginal  mucous  membranes 
have  thus  been  brought  into  apposition,  Lauenstein  diminishes  the 
depth  of  the  wound  posteriorly  by  some  buried  stitches.  Then  he 
unites  the  perinaeum  with  silver  wire.  In  complete  laceration  the 
anterior  angle  of  the  denudation  of  the  septum  should  be  first 
closed  with  sutures  placed  in  the  usual  manner  (Figs.  307  and  308). 


Fig.  306. — Suture  in  perineorrhaphy.     Hepner's  method. 

A.  Martin's  method,  (suture). — Martin  makes  a  denudation  analo- 
gous to  that  of  Simon,  but  employs  a  very  expeditious  method  of 
suture  that  secures  as  perfect  a  coaptation  as  that  obtained  by  the 
ingenous  and  complicated  sutures  invented  by  Hildebrandt  and 
Heppner.  He  begins,  as  in  colporrhaphy,  at  the  superior  angle  of 
the  wound,  closing  the  rectum  first  -nith  stitches  which  take  up  the 
rectal  mucosa,  peiietrate  into  the  raw  surface  and  pass  out  iuto  the 


Laceration  of  the  Perinceum. 


558 


rectum.  The  intestinal  laceration  closed  to  the  anus,  he  makes, 
with  the  same  thread,  a  first  row  of  sutures  in  the  wound  itself, 
mounting  up  the  vagina  to  the  superior  angle,  the  .primary  starting 
point.  If  this  single  row  is  sufficient,  the  lips  of  the  vaginal  wound 
are  united,  then  those  of  the  perinaeum.  If,  on  the  contrary,  the 
raw  surface  permits  too  great  a  surface,  a  second  tier  of  sutures  is 
placed  before  the  final  occlusion  (Fig.  309). 


Fig.  307.  —  Incomplete  laceration  of  the  perinEeum.  Suture  by  Lauenstein's 
method,  i.  Suture  of  the  anterior  angle  of  the  denudation.  2.  Submucous  suture  of 
the  vaginal  wall.     3.  Buried  suture  in  the  depth  of  the  wound. 


Fig.  308. — Complete  laceration.     Suture  by  Lauenstein's  method,     i.  Suture  for 
coaptation  of  the  vaginal  and  rectal  mucosas.     2.  Introduction  of  the  perinseal  sutures. 


554  Laceration  of  the  Perinceum. 

LaFort's  method  may  be  applied  to  complete  lacerations,  in- 
volving a  large  extent  of  the  septum.  An  incision  one  centimetre 
long  is  made  at  the  point  C  (Fig.  310,  1)  involving  only  the  depth 
of  the  vaginal  portion  of  the  septum.  Then  an  incision  is  carried 
on  the  line  C  D  E  to  the  point  E.  From  the  point  C,  a  second 
incision  C  G,  on  each  side,  follows  the  rectal  portion  of  the  septum 
to  the  side  of  the  anus,  but  without  involving  the  rectal  mucosa. 


Fig.  309. — Complete  laceration.     Martin's  method,     a,  deep  row  of  the  continued 
suture ;  d,  second  tier  of  stitches. 

These  two  incisions  are  united  by  a  third  incision  E  I  G,  marking 
out  a  triangle  H,  witliin  which  the  skin  and  the  cicatrix  are 
removed,  leaving  a  triangular  denuded  surface  on  each  side.  The 
vaginal  leaflet  of  the  septum  and  the  anterior  border  of  the  incision 
C  D  E  is  then  seized  with  the  forceps  and  separated  by  dissection 
to  the  dotted  line  C  E,  giving  the  small  vaginal  flap  D,  which  unites 
by  its  deep,  raw  surface  with  that  of  the  other  side.  The  suture  is 
done  in  three  parts :  a  rectal  plane  formed  by  the  suture  of  the  two 
edges  of  the  rectum ;  a  vaginal  plane  formed  by  union  of  the  two 
flaps  D,  and  a  large  intermediate  plane  formed  by  coaptation  of  the 
two  denuded  triangles  H  (Fig.  310,  2,  3,  4). 

Emmet's  method. — The  denudation  represents  on  each  side  of  the 
lacerated  periuseum  a  triangle,  the  base  being  formed  by  the  skui, 
one  of  the  sides  follomng  the  vaginal  wall  to  the  inferior  fourth  of 
the  labium,  while  the  other  passes  beyond  the  anterior  limit  of  the 
anal  orifice  to  join  the  cutaneous  incision.  The  two  triangles  are 
connected  in  the  median  line  by  a  small  denudation  made  at  the 
expense  of  the  inferior  portion  of  the  recto- vaginal  septum,  and  to 
the  extent  of  three  centimetres  high.     The  figure  which  results  from 


Laceration  of  the  Perinaum. 


555 


the  denudation  may  be  compared  to  a  butterfly  with  spread  wings, 
the  median  denudation  representing  the  body  of  the  animal  and  the 
lateral  portions  the  wings  (Fig.  311).  The  suture  is  one  of  the 
special  features  of  Emmet's  operation.  Silver  wu-e  of  medium 
size  is  usually  employed.  The  operator  enters  the  point  of  the 
needle  on  the  left  side  of  the  perinseum,  at  one  centimetre  and  a 
half  behind  and  outside  the  anus.  Pushing  the  point  forward,  he 
passes  it  through  the  inferior  part  of  the  recto-vaginal  septum.to 
emerge  on  the  right  side  of  the  anus,  at  a  point  symmetrically 
opposite  the  point  of  entrance.  During  this  time  the  introduction 
of  the  left  index  finger  in  the  rectum  is  absolutely  indispensable. 
It  draws  the  recto-vaginal  septum  tense,  guides  the  passage  of  the 
needle,  and  prevents  it  from  penetrating  the  rectum.  Four  or  five 
threads  in  succession  are  placed  in  this  manner  above  the  preceding. 


Fig.  310. — Complete  laceration  of  the  perinseum.  Le Fort's  method.  I.  Tracing 
of  the  incisions.  2.  Reconstruction  of  the  rectal  wall.  3.  Reconstruction  of  the 
vaginal  wall.     4.  Suture  in  vertical  section. 

Generally,  five  or  six  stitches  are  sufficient  for  complete  coaptation ; 
if,  however,  the  region  of  the  fourchette  is  not  sufficiently  closed,  a 
superficial  stitch  in  this  region  will  be  necessary.  In  the  same 
way,  if  the  cutaneous  lips  of  the  perinseal  incision  are  not  in  perfect 
contact,  a  few  supplementary  superficial  stitches  may  be  used.  The 
operation  is  thus  completed. 
Lawson  TaWs  method. — This  procedure  differs  little  from  that 


356 


Laceration  of  the  Periiueitm. 


Fig.  311. — Complete  laceration.     Emmet's  method.     Denundation  and 

disposition  of  the  threads. 


Fig.  312. — Securing  the  posterior  suture.     Emm»i's  method. 


Laceration  of  the  PeriiKeum. 


557 


addressed  to  incomplete  lacerations,  that  I  have  already  described. 

Here,  also,  the  surgeon  begins  by  splitting  the  recto- vaginal  septum 

to  form  a  rectal  flap  and  a  vaginal  flap.     The  greater  the  tear,  the 

greater  the   depth   of   the    denudation. 

The  flap-splitting  is  foUowed  laterally  to 

vertical  lines  passing  to  the  junction  of 

the  labia  minora  and  majora.     To  these 

lines,  sufi&cient  in  incomplete  lacerations, 

should    be   added   a   posterior   incision 

giving  the  line  of  incision  the  orm  off  a 

letter  H,  in  which  the  transverse  bar,  in 

place  of  being  in  the  center,  approaches 

the  inferior  portion  (Fig.  315).     These   two  flaps  when  dissected 

form  a  quadiilateral  surface,  at  the  bottom  of  which  is  the  intact 

septum  (Fig.  316). 

Simpson's  method. — In  a  chi-onological  point  of  view,  this  should 
have  received  description  before  that  of  Lawson  Tait,  but  as  it  is 
of  less  importance,  I  introduce  it  here  mainly  as  an  appendix.  A 
first  incision  starts  from  the  extremity  of  the  septum,  between  the 
rectum  and  the  vagina,  and  following  the  internal  surface  of  the 
labia  majora  from  within  outward  (Fig.  317),  ends  at  point  1. 


Fig.  313. — Schema  of  the  su- 
ture of  the  sphincter  in  Emmet's 
method. 


Fig.  314. — Vertical  section  of  all  the  sutures.     Emmet's  method. 

Another  incision  is  made  from  the  point  a  parallel  to  the  vulvar 
orifice,  passing  by  the  external  extremity  of  the  first  incision  and 
stopping  at  h,  at  the  extremity  of  the  torn  sphincter.  The  opposite 
side  is  operated  in  like  manner.  The  two  triangles  thus  obtained 
are  dissected  (Fig.  318).  The  flap  a  1  S  is  lifted  above  the  vagina 
on  each  side,  so  that  the  angles  designated  by  the  figure  1  in  the 
first  illustration  are  joined  in  the  second.  The  vaginal  flaps  are 
sutured  with  silver  wire  or  with  silk.  The  ends  of  the  sutures  are 
left  long  and  pendant  in  the  vagina.  On  the  rectal  side  catgut  is 
better,  the  ends  being  cut  short.     To  close  the  cavity,  hat  remains 

o  deep,  perinaeal  sutures  are  applied. 

Fritsch's  method. — This  procedure  corresponds  still  more  nearly 
to  Tait's.     It  depends  on  the  principle  of  flap-sphtting.     Fritsch 


558 


Laceration  of  the  Perinceum. 


limits  himself  to  detaching  the  rectum  from  the  vagina,  in  incom- 
plete tears,  and  in  complete  laceration  he  adds  a  lateral  incision  to 
seek  the  retracted  extremities  of  the  sphincter.  He  sutures  the 
rectal  mucosa  with  interrupted  stitches  of  catgut,  placed  thi-ough 
the  vagina  and  tied  in  the  bottom  of  the  wound.  The  sutm-es 
should  not  penetrate  into  the  rectum,  to  avoid  infection  of  the 
wound  along  the  suture  track.  The  same  variety  of  buried  suture 
close  the  vagina  without  penetrating  it.  It  only  remains  to  sutui'e 
the  perineal  wound  with  a  series  of  buried  sutures  in  superposed 
rows.  If  the  laceration  of  the  septum  extends  high  up,  it  may  be 
necessary  to  separate  it  and  sutm-e  according  to  the  same  principles 
(Fig.  319). 


Fig.  315. — Tracing  of  the  incisions.     Lawson  Tail's  method,     abed,  incision  for 
incomplete  laceration,     a  b  c  d  e  f ,  incision  for  complete  laceration. 

After-treatment  in  perinteorrhai^hy. — The  essential  points  are  great 
care  in  the  matter  of  cleanliness  and  of  local  apphcatious  of 
iodoform.  It  is  preferable  to  catheterize  the  patient  the  first  few 
days  to  avoid  the  passage  of  urine  over  the  wound.  An  important 
point  is  the  management  of  the  bowels  for  several  days  after  the 
operation.  The  best  plan  is  to  keep  the  patient  on  a  milk  diet 
during  the  fii-st  week,  and  to  give  a  mild  purgative  about  the  fifth 
day.  After  one  or  two  stools,  further  movements  are  prevented  by 
the  use  of  a  Uttle  opium.  The  bowels  are  opened  again  four 
days  later.  Soon  after  the  operation  the  patient  is  sometimes 
tormented  by  gas.  The  difficulty  may  be  relieved  by  i)assing  a  soft 
gum  catheter  to  the  depth  of  six  to  eight  centimetres  into  the  rectum 
several  times  a  daj'.  The  limbs  should  be  brought  together  and 
lightly  secured.  The  woman  is  not  permitted  to  sit  up  for  thi'ee 
weeks.     In  general,  the  perineal  sutures  are  removed  as  soon  as 


Laceration  of  the  Perlncsum. 


559 


they  begin  to  irritate  the  tissues,  toward  the  tenth  or  twelfth  day. 
Vaginal  sutures  are  removed  last.  The  patient  should  walk  only  at 
the  end  of  two  months.  Sexual  relations  should  be  forbidden  for 
six.  months. 


Fig.  316. — Complete  laceration.     Tait's  method. 


Fig.  317. — Complete  laceration.    Simp-       Fig.  318. — Sutures.    Simpson's  method, 
son's  method;  denudation. 


Prognosis. — -To-day,  perinseorrhaphy  is  not   a  grave  operation. 
There  is  neither  marked  hemorrhage  to  be  feared,  nor  septicsma. 


560 


Laceration  of  the  Perinceiim. 


Cases  of  the  last  variety  of  complication  that  have  been  reported, 
are  all,  Avith  rare  exceptions,  of  an  old  date.  The  results  are  also 
more  perfect  since  we  have  now  scarcely  any  fear  of  suppuration. 


Fig.  319.- 

labia  majora 


-Fritsch-Walzberg  method.     S,  recto-vaginal  septum;   f,  lacerations; 
1,  nymphse;   P,  perinseum ;   F,  rectal  portion  of  the  flap. 


Fig.  320. — Fritsch-Walberg  method.     R, rectum;  V,  vagina;   abb',  incision. 
I.  Incision.     2.  Flap  splitting.     3.  Reunion. 

Choice  of  i^roeedure.  —Each  one  of  the  various  methods  that  have 
been  described  has  given  satisfactory  results.  It  may  then  be  said 
that  they  are  all  good.  However,  all  things  being  equal,  it  is 
evident  that  the  preference  should  be  given  to  that  which  has  the 
advantage  in  point  of  simplicity  and  rapidity  of  execiition.  This 
is  the  reason  why  Tait's  operation  is  so  miich  in  vogue  to-day. 
Many  surgeons,  however,  accept  it  only  for  incomplete  laceration. 
It  has  been  accused,  even  then,  of  creating  a  smaU  cul-de-sac  l)ehind 
the  fourchette.  In  complete  lacerations,  success  -with  Tait's 
method  are  less  numerous,  and  many  operators  prefer  the  older 
methods  that  have  stood  trial. 


Diseases  of  the  Vulva.  561 


CHAPTER  XLIII. 


DISEASES   OF   THE  VULVA. 

Inflammation  of  the  vulva. — Pathological  anatomy. — Tlie 
vulva  is  made  np  of  very  distinct  anatomical  structures ;  it  com- 
prises the  cutaneous  folds,  the  labia  majora,  the  mucous  folds,  the 
labia  minora  and  the  hymen ;  it  presents  also  the  opening  of  the 
meatus  urinarius  and  the  mouths  of  the  glands  of  Bartholin.  In- 
flammation affecting  these  different  parts  takes  on  various  char- 
acters. Attempt  has  been  made  to  indicate  the  chief  divisions  by 
distinguishing  a  sebaceous  vulvitis  and  a  mucous  vulvitis.  But,  in 
most  cases,  all  the  parts  entering  into  the  anatomy  of  this  region 
are  affected  by  a  diffuse  inflammation.  Inguinal  adenitis  is  a 
frequent  consequence  of  cutaneous  vulvitis.  A  suppuration  of  the 
loose  cellular  tissue  of  the  labia  majora  rarely  occurs  outside  the 
puerperal  state,  but  the  glands  of  Bartholin  are  quite  easily  invaded. 

Symptoms. — A  sharp  local  pain,  aggravated  by  walking  and  by 
contact  with  the  urine,  is  the  first  symptom  noted  by  the  patient. 
A  more  or  less  abundant  oozing,  sometimes  fetid,  irritates  the 
internal  surface  of  the  thighs.  Erosions  may  occur ;  their  grayish 
base  and  the  glandular  swelling  may  simulate  a  syphilitic  lesion. 
The  mucosa  of  the  nymphse,  of  the  fourchette,  and  of  the  vestibule 
is  red  and  swollen;  grumous  pus,  mixed  with  smegma,  collects 
between  the  labia  majora  and  minora.  The  skin  of  the  former  is 
(Edematous  and  marked  by  small  pustules.  The  larger  of  these 
resemble  furuncles.     SmaU  circumscribed  abscesses  may  result. 

Huguier  has  described  the  cutaneous  form  under  the  term  follicu- 
lar vulvitis,  making  thi-ee  periods,  one  of  eruption,  one  of  suppur- 
ation and  one  of  decline.  Termination  may  exceptionally  occur  by 
induration.  The  particular  form  of  the  small  tumor  which  results 
resembles  that  of  sebaceous  acne. 

The  intensity  of  the  inflammation  is  variable.  When  it  is  very 
acute,  it  may  cause  fever ;  there  is  then  usually  a  complication  of 
lymphangitis  and  suppurative  inguinal  adenitis.  It  is  to  lymphan- 
gitis that  vulvitis  phlegmonosa  should  be  attributed.  The  inflam- 
mation of  the  orifice  of  the  urethra  causes  dysuria.  If  the  gland  of 
Bartholin  becomes  inflamed  it  presents  a  perceptible  tumor,  and, 
on  pressure,  pus  issues  from  its  duct. 

Diagnosis. — Vulvitis  is  easy  to  recognize,  but  the  important  point 
is  to  determine  exactly  the  complications  on  the  side  of  the  uretlu-a, 


662  Diseases  of  the  Vulva. 

of  the  vulvo-vaginal  glands  or  of  the  vagina.  The  aetiological  diag- 
nosis also  presents  some  difficulty  in  certain  cases.  It  should  not 
be  forgotten  that  lymphatic  children  under  bad  hygienic  conditions 
may  suffer  from  an  intense  catarrhal  ^'ulvitis,  that  occurs  without 
contagion,  by  simple  decomposition  of  smegma,  and  causes  erosions 
and  even  ulcerations.  One  should  not  be  too  hasty,  then,  in  the 
absence  of  other  proof,  in  deciding  on  rape  or  on  contagion. 

JEtiologi/. — ^Of  all  causes  of  vuhitis,  the  most  frequent  is  certainly 
gonorrhoeal  contagion.  In  children  ascarides  act  as  an  irritant.  In 
case  of  vesico-vaginal  fistulffi,  the  incessant  contact  of  the  urine 
irritates  the  xl^lva,  as  well  as  the  inside  of  the  thighs. 

Treatment. — In  acute  periods,  baths,  abundant  lotions  of  borated 
water,  extreme  cleanliness,  and  repose,  should  be  advised.  If  a 
blemiorrhagic  affection  is  suspected  a  weak  solution  of  silver  nitrate 
(1-50)  is  painted  on  the  parts.  This  considerably  diminishes  the 
pain.  Lotions  and  injections  of  sublimate  (1-.5000)  should  also  he 
prescribed.  The  vulva  may  be  powdered  with  pulverized  talc  with 
the  addition  of  one-tenth  of  iodoform.  If  the  opening  of  the  vulvo- 
vaginal gland  is  inflamed  it  should  be  cauterized  with  a  pencil  of 
nitrate  of  silver,  after  having  enlarged  it  a  Httle  with  Weber's 
lachrymal  knife.  If  the  periurethral  crypts  are  affected  ignipuncture 
will  be  useful.     Abscesses  and  biiboes  should  be  opened  at  once. 

(Sdeiua. — Localized  oedema  of  the  vulva  is  sometimes  observed 
during  pregnancy  on  account  of  the  obstruction  of  the  pelvic  circu- 
lation and  of  the  presence  of  varices  of  the  external  pudic  veins. 
In  the  puerperal  state,  a  little  after  delivery,  if  oedema  of  one  side  of 
the  Milva  is  observed,  it  is  a  sure  index  of  a  local  infection,  and  a 
tear,  an  eschar,  or  a  phlegmon  wiU  be  discovered  in  the  vagina. 

In  general  anasarca  the  labia  majora  are  swollen  to  the  extreme ; 
micturition  and  catheterization  may  be  difficult.  Spontaneous 
erosions,  or,  smaU  openings  intentionally  made  in  the  skin,  afford 
exit  to  serum,  but  are  often  the  point  of  entrance  for  erysipelas. 

In  syphilitic  lesions  of  the  vi;lva,  and  especially  in  infecting 
chancre,  there  is  sometimes  observed  a  hard  oedema,  quite  pecuUar, 
which  often  attracts  the  patient's  attention  much  more  than  the 
chancre  itself.  This  oedema,  Avhich  long  sur\ives  the  heahng  of  the 
ulceration,  is  especially  marked  in  the  labia  minora  which  it  trans- 
forms into  a  sclerosed  hypertrophied  tissue  apparently  elephantiasic. 

Gangrene  of  the  vulva  may  be  caused  by  the  traumatism  of 
delivery,  when  to  this  local  cause  is  added  the  influence  of  general 
infection.  Other  septicemias  may  have  the  same  effect — typhus, 
measles,  scarlatina,  variola,  etc.  In  debiUtated  and  scrofulous 
children,  gangrene  of  the  w\\\-a  may  assume  the  character  of  noma ; 
it  may  also  be  epidemic  and  fatal.  The  treatment  should  include 
antisepsis  of  the  vagina  and  isolation  of  the  walls  to  prevent  the 
formation  of  adhesions. 


Diseases  of  the  Vulva.  563 

Erysipelas. — Primary  erysipelas  of  the  Yulva  often  occurs  in  the 
new-born.  It  is  then  a  very  grave  disease  and  frequently  terminates 
in  death.  In  menstruating  women  there  is  sometimes  observed,  at 
the  time  of  the  menses,  a  periodical  erysipelatous  attack.  It  is 
probable  that  the  pathogenetic  microbes  persist,  but  remain  latent 
until  aroused,  each  month  by  the  congestion  of  the  menstrual 
period.  As  a  treatment,  local  applications  of  powdered  talc,  of 
oxide  of  zinc,  or  of  etheral  tincture  of  cami^hor,  give  some  relief. 
Huter  and  Boeckel  have  recommended  hypodermic  injections  of  a 
carbolic  solution,  2  or  3  to  100,  on  the  limits  of  the  erysipelatous 
plaque,  renewed  morning  and  evening.  Lucke  advises  frictions 
with  turpentine. 

Eczema. — Eczema  may  assume  an  acute  or  chronic  character.  In 
the  acute  form  the  onset  is  sudden  and  is  manifested  by  a  sense  of 
burning,  soon  followed  by  tumefaction  and  intense  redness.  Small 
transparent  vesicles,  the  size  of  a  pin  head,  are  strewn  over  the 
skin,  but  they  are  sometimes  difficult  to  distinguish  because  they 
have  been  broken  by  scratching.  To  discover  them  the  skin  should 
be  examined  looking  obliquely  upon  it  under  a  lateral  illumination. 
There  is  often  a  little  gastric  distm-bance  and  catarrhal  fever.  These 
eruptions  occur  particularly  in  the  spring,  in  arthritic  subjects. 
At  the  end  of  a  fortnight  the  acute  affection  subsides  but  the  dis- 
ease may  take  on  a  chronic  form.  Chronic  eczema  most  frequently 
takes  the  form  of  eczema,  ruhrum  (Hebra).  While  in  the  acute  form 
the  labia  majora  only  are  affected,  here  the  disease  may  attack  the 
mons  veneris,  the  internal  surface  of  the  thighs,  the  perinseum  and 
the  anus. 

According  to  Hebra,  the  majority  of  cases  of  this  affection  are 
found  in  patients  who  are  subject  to  menstrual  troubles.  The 
influence  of  diabetes  mellitus  has  been  noted.  That  of  an  arthritic 
diathesis  is  not  to  be  doubted. 

The  treatment  in  the  acute  period  consists  in  the  application  of 
cataplasms  and  in  the  frequent  employment  of  laxatives.  A  diet 
that  excludes  spices  and  fats  should  be  prescribed.  In  chronic 
cases,  sublimate  douches,  1-1000,  may  be  employed  to  great 
advantage ,  also,  an  ointment  containing  two  grammes  of  oxide  of 
zinc  and  one  gramme  of  iodoform  to  thirty  grammes  of  lanoline. 
General  treatment  miist  not  be  neglected  in  the  arthritic,  scrofulous 
or  diabetic  diatheses. 

Herpes. — This  affection  is  characterized  by  small,  transparent 
vesicles,  from  the  size  of  a  pinhead  to  that  of  a  lentil,  occurring  in 
groups  of  small  or  large  number  (discrete  or  confluent).  A  rare 
form  is  solitary  herpes  (Fournier)  which  consists  of  a  single  erosion, 
sometimes  presenting  a  larger  surface  and  resulting  in  excoriation 
from  a  single  group  of  vesicles. 

The  eruption  appears  in  many  cases  a  day  or  two  before  the 


664  Esthmnene  of  the  Vulva. 

menstrual  period.  In  some  women  it  is  thus  reproduced  peri- 
odically. It  often  occurs  also  during  pregnancy.  The  congestion 
of  the  genital  organs  is  then  evidently  a  predisposing  cause.  Any 
irritation  of  the  vulva  may  cause  an  accidental  herpes,  as,  for  ex- 
amijle,  hlennorrhagic  or  syphihtic  infection,  negligence  of  hygiene. 
Herpes  may  also  he  constitutional. 

The  treatment  should  be  dii-eeted  to  the  reUef  of  pain,  by  pro- 
longed l)aths  and  cataplasms,  cure  of  the  ulcerations  by  powdering 
with  a  mixture  of  equal  parts  of  pulverized  oxide  of  zinc,  subnitrate 
of  bismuth  and  iodoform.  The  vesicles  may  also  be  touched  with 
a  solution  of  nitrate  of  silver,  1-50.  The  general  health  should 
receive  attention  at  the  same  time,  to  prevent  the  return  of  the 
lesion,  which  especially  depends  upon  a  diathetic  cause. 


CHAPTER  XLIV. 


ESTHIOMENE   OF   THE   VTJXVA. 

The  term  esthiomene,  or  lupus,  of  the  vulva  has  retained  since 
Hugnier  first  described  it  a  pui'ely  clinical  significance.  It  has 
been  appKed,  without  doubt,  to  a  variety  of  lesions  presenting  as  a 
common  character  a  tendency  to  hypertrophy,  at  the  same  time 
■with  a  slow  and  progi-essively  destructive  ulceration  of  the  vulvar 
region,  without  the  tendency  to  invade  the  glands  and  contiguous 
parts.  This  lesion,  which  characterizes  cancer,  has  been  justly 
compared,  in  certain  cases,  to  that  of  lupus  of  the  face,  in  respect 
to  its  external  appearance  and  its  progress.  However,  the 
tubercular  nature  of  esthiomene  of  the  vulva  remains  to  be  proven. 

Pathological  anatomy. — Since  every  ulceration,  of  slow  in-ogi'ess 
and  attended  with  hypertrophy  of  its  edges,  has  been  called  lupus, 
it  is  not  sui-prising  that  the  most  diverse  histological  lesions  have 
been  met  with.  There  have  been  found  a  series  of  alterations 
comparable  to  those  of  elephantiasis  (Eenant),  and  the  lesion  of 
tubular  epithelioma  (Cornil).  At  other  times,  all  the  changes  are 
limited  to  those  of  inflammation  of  the  skin,  to  an  infiltration  of 
the  connective  tissue  by  embryonic  tissues,  principally  around  the 
dilated  vessels  (Figs.  321  and  322). 

Si/mjitoms. — Two  clinical  types  may  be  recognized,  according  as 
it  is  the  ulceration  or  the  hyiiertrophy  which  predominates. 

1.  Ulcerous  form. — Erythematous  esthiomene  is  a  veiy  super- 
ficial ulceration,  of  a  livid  red  color,  like  lupus  of  the  face.     Tu- 


Esthiomene  of  the  Vulva. 


5Go 


berciilar  esthiomene  is  distinguished  by  disseminated  hyper tropliied 
projections  which  push  up  the  base  of  the  ulcer.  One  of  its  most 
important  characters  is  the  faciUty  with  which  cicatrization  occurs 
spontaneously  on  one  side,  while  the  ulceration  progresses  at  the 
other.  The  ulcer  is  called  serpiginous  when  it  pushes  out  long  and 
sinuous  prolongations  toward  the  vestibule,  perforating  when  it  bur- 
rows deeply.  The  flow  from  the  ulceration  is  not  abundant.  Deep 
perforations  and  fistulse  of  the  rectum  and  bladder  may  occur.  A 
partial  cicatrization  may  cause  narrowing  of  the  meatus  urinarius 
or  of  the  anus. 


Fig.  321. — Esthiomene  of  the  vulva  (Thin),    a,  normal  epithelium;  b,  bloodvessel; 
c,  infiltration  of  small  cells;   d,  fusiform  connective  tissue  cell. 


2.  Hypertrophic  form. — In  this  form  the  hypertrophy  assumes 
extreme  proportions.  The  labia  majora  becomes  double  or  treble 
in  volume,  and  appear  infiltrated  with  an  oedema,  which  gives  them 
an  elastic  consistency.  In  different  points  of  the  contiguous  skin 
there  exist  disseminated  tubercles  that  may  invade  the  whole 
surface  of  the  perinseum.  The  surface  is  polished,  shining,  red  or 
violaceous.  These  indurated  parts  are  rarely  painful,  unless 
momentarily  inflamed,  though  caruncles  of  the  meatus  urinarius 
are  usiially  very  sensitive.  The  hypertrophied  and  ulcerous  forms 
are  sometimes  isolated,  but  they  are  more  frequently  confused  in  a 
mixed  form. 

Diagnosis. — The  slow  progress  of  the  ulceration,  its  accompanying 
hypertrophy,  the  absence  of  marked  glandular  enlargement,  will 
distinguish  it  from  phagedenic  chancre,  from  tertiary  syphiUdes 
and  fi-om  cancer. 


566 


Esthiomene  of  the  Vulva. 


Prognosis. — The  prognosis  is  gi'ave,  though  the  progress  of  the 
disease  may  be  slow,  sometimes  covering  a  period  of  eight  or  ten 
years. 


Fig.  322. — Esthiomene  of  the  vulva  (Thin),  i.  a,  infiltration  by  small  cells;  b, 
transverse  section  of  bloodvessel;  c,  longitudinal  section  of  bloodvessel.  2.  En- 
larged four  diameters,  a,  epithelium ;  b,  bloodvessel ;  c,  connective  tissue  containing 
cells;  d,  connective  tissue  well  developed.  3.  More  highly  magnified,  a,  leucocyte; 
b,  fibrous  tissue  in  the  process  of  formation ;  c,  flattened  fusiform  cell.  4.  a  a,  blood- 
vessel cut  transversely ;   b,  fusiform  cell. 

jEtiology. — Esthiomene  is  a  rare  affection.  It  is  most  frequently 
obsei-ved  between  the  ages  of  twenty  and  thirty,  and  in  prostitutes. 
An  important  predisposing  cause  appears  to  be  tuberculosis.  AH 
causes  leading  to  a  low  state  of  health,  privations,  excesses, 
hereditary  syphilis,  predispose  to  esthiomene. 

Treatment. — This  consists  essentially  in  the  cauterization  of  the 
ulcers  and  the  excision  of  the  hypertrophied  portions.  The  actual 
cautery  is  preferable  to  the  potential  caustics.  Scarifications  and 
curetting  offer  chances  of  success  only  in  the  erythematous  or 
superficial  form.  Iodoform  dressings  and  touching  with  tincture 
of  iodine  have  also  been  attended  with  some  success. 


Tumors  of  the  Vulva.  667 


CHAPTER  XLV. 


TUMORS   OF   THE   VULVA. 

Varicose  tumors. — During  pregnancy  varices  of  the  labia  are  often 
observed.  Varicose  tumors  may  attain  a  considerable  size.  Holden 
cites  a  case  where  the  labia  majora  attained  the  size  of  a  foetal 
head,  the  patient  dying  of  phlebitis.  More  frequently,  the  varices 
only  cause  a  sense  of  weight  and  difficulty  in  walking.  They  present 
the  appearance  of  small,  bluish  tumors,  violaceous  on  the  mucous 
side.  They  produce  grave  haemorrhage  when  they  are  ruptured  in 
consequence  of  traumatism.  This  rupture  may  even  occur  spon- 
taneously. Several  cases  of  fatal  hsemorhage  have  been  observed. 
The  varicose  region  should  be  supported  with  a  light  compress  and 
a  T  bandage. 

Hcematoma  or  thrombus. — The  subcutaneous  rupture  of  a  varicose 
vein  is  the  cause  of  hcematoma  of  the  vulva.  It  usuahy  occurs 
during  labor.  Outside  of  the  pregnancy,  hsematoma  has  been 
observed  only  after  blows  or  falls,  and  its  dimensions  are  then  quite 
small.  Only  a  single  lip  of  the  vulva,  in  most  eases,  is  affected.  It 
soon  assumes  a  violet  color,  and  may  reach  the  size  of  a  foetal  head. 
It  is  a  grave  complication  of  labor.  Out  of  one  hundred  and 
twenty  cases  collected  by  Girard,  there  were  twenty-four  deaths. 

Simjde  vegetations. — These  have  also  been  designated  as  condy- 
lomata and  papillomata.  These  tumors  are  cauliflower  ex- 
cressences,  sometimes  very  large,  consisting  of  hypertrophy  of  the 
papiUse,  of  the  skin  or  of  the  vulvo-vaginal  mucosa.  Often  isolated, 
in  the  form  of  a  cock's  comb,  they  may,  when  agglomerated,  form 
masses  the  size  of  a  fcetal  head.  Their  color  is  light  red  or  wine 
color.  They  are  seated  over  the  whole  extent  of  the  vulva,  the 
perinaeum  and  the  margin  of  the  anus,  and  are  even  seen  in  the 
vagina.  They  are  attended  with  a  sanious  and  fetid  discharge.  The 
friction  of  walking  inflames  them,  and  makes  them  painful.  These 
vegetations  have  long  been  considered  as  the  constant  sign  of  a 
venereal  infection,  blennorrhagie  or  syphilitic.  But  they  are  also 
observed  in  pregnant  women  affected  with  a  simple  leucorrhoea. 
The  transmission  of  vulvar  papillomata  by  contact  has  not  been 
proven. 

Treatment. — The  best  and  the  most  simple  treatment  is  excision 
with  the  scissors,  under  continuous  irrigation,  followed  with  cauter- 
ization of  the  base  of  the  tumors  with  the  thermo-cautery. 


568 


Tumors  of  the  Vulva. 


Elephantiasis  is   an   liypei"plasia  of   the   skin  and   of  the  sub- 
cutaneous cellular  tissue. 

Pathological    anatomy. — The   hypertrophied  labia    majora  form 
voluminous  masses  which  may  exceed  the  size  of  an  adult  bead. " 
Their  base  is  most  frequently  broad,  but  they  are  in  some  cases 
pedunculated. 


Fig.  323. — Simple  vegetations  of  the  vulva  (Tarzier). 

Symptoms. — The  principal  sj^mptom  is  the  tumefaction  which 
may  become  sufficient  to  obstruct  mictuiition  and  walking.  Ulcer- 
ations maj'  be  produced  by  friction  but  they  have  a  natural  tendency 
to  heal.  The  thickening  of  the  tissues  may  invade  the  perineal  and 
anal  regions  and  form  enormous  tumors.  Amenorrhoea  is  frequently 
observed. 

Treatment. — The  only  rational  treatment  is  ablation.  I  believe 
that  the  knife  is  preferable  to  the  eeraseur,  to  the  thermo- cautery 
or  to  the  galvano-cautery.  The  wound  will  heal  by  first  intention. 
Suppuration  here  would  be  particularly  dangerous  on  account  of 
the  great  development  of  the  lymphatics. 

Fibroids  and  fdiro-myomas. — Myxomas. — These  tumors  usually 
arise  in  the  labia  majora,  although  they  have  also  been  found  on 
the  perinaeum  and  labia  minora.  They  contain  pure  fibrous  tissue 
or  a  mixture  of  nonstriated  miiscular  fibres,  or,  again,  a  mj'xo- 
ma^ous  tissue.  They  are  often  pedunculated,  forming,  when  their 
consistency  is  soft,  one  of  the  variety  called  by  the  old  writers  mol- 
luscum  penduhnn,  and  what  has  more  recently  been  described  under 


Tv/mors  of  the  Vulva. 


569 


the  term  molluscum  simplex.  These  tumors  are  benign  and  of  slow 
progress.  They  may  be  enucleated,  or  their  pedicle  cut,  without 
danger  of  hemorrhage. 


Fig.  324. — Elephantiasis  of  the  vulva. 

Lipomata  of  the  vulvar  region  take  their  origui  fi'om  the  fatty 
ayer  of  the  labia  majora  or  of  the  mons  veneris.  They  may  attain 
large  proportions.     Their  extirpation  presents  no  difficulty. 

Enchondroma  of  the  vulvar  region  is  a  pathological  rarity.  Only 
a  few  cases  have  been  cited. 

Neuromata. — I  have  found  only  two  cases  reported,  one  by  Simp- 
son and  one  by  Kennedy. 

Cysts  of  the  vulva. — I  shall  describe  later  the  cysts  of  the  glands 
of  Bartholin,  which  form  the  great  majority  of  this  class  of  tumors 
of  the  vulva.  Independent  of  these,  there  may  exist  cysts  of  a 
different  origin  on  various  parts  of  the  vulva. 

A.  Of  the  labia  majora,  superficially,  sebaceous  cysts.  Deeply 
serous  cysts,  which  some  authors  call  encysted  hydrocele  of  the 
round  ligament.  Finally,  several  cases  of  dermoid  cysts  have  been 
reported. 

B.  At  the  vestibule  and  between  the  meatus  urinarius  and  the 
clitoris  cysts  have  been  observed,  the  size  of  a  bean,  containing  a 
serous  or  a  yellow  liquid  and  are  lined  with  cylindrical  epithelium. 
They  probably  arise  from  small  sebaceous  glands. 

C.  At  the  side  of  the  meatus  urinarius  Kocks  has  described  a 
very  short  cul-de-sac,  the  terminal  remains  of  Gartner's  canal. 


570  Tumors  of  the  Vulva. 

D.  Congenital  cysts  have  been  observed  on  the  hymen  by 
Winckel.  They  are  very  small  and  contain  the  product  of  the  dis- 
integration of  pavement  epithelial  cells. 

Vascular  tumors  of  the  meatus  urinarius. — Simon  and  Verneuil  have 
described  these  growths  under  the  term  papillary  polypi  and  have 
insisted  on  their  great  vascularity.  According  to  Virchow,  what 
differentiates  these  neoplasms  from  ordinary  telangiectasic  tumors 
is  merely  that  the  walls  of  the  vessels  are  not  thick  and  dilated.  In 
short,  it  seems  that  they  are  due  simply  to  an  abnormal  growth  of 
erectile  tissue  in  a  region  which  to  its  development  is  normal  in  man, 
but  which  in  woman  is  normally  devoid  of  it.  The  tumors  tend 
to  become  pedunculated,  owing,  no  doubt,  to  the  effect  of  mictu- 
rition. There  are  some  cases  where  the  tumor  is  formed  by  the 
prolapsed  mucosa  rather  than  by  a  distinct  polypus.  I  do  not 
believe  that  this  prolapsus  of  the  urethi-al  mucosa  is  essentially 
different  from  polypoid  gro\vths,  for  it  always  coincides  with  a 
notable  increase  of  vascularity. 

AUtiology. — This  affection  is  sometimes  met  with  in  young  gu-ls. 
It  is  toward  middle  age,  however,  that  these  lesions  most  fi-equently 
occur.  It  is  also  observed  in  the  aged.  '  All  causes  of  local  irri- 
tation of  the  meatus,  of  coiagestion  of  the  pelvic  organs,  of  inflam- 
mation of  the  urinary  passages  in  adults,  of  debility  or  of  general 
cachexia  in  children,  favor  their  development. 

Symptoms. — To  obtain  a  good  view  of  the  polypi  it  is  necessary  to 
separate  the  nymphs  and  to  press  upon  the  urethi-a  with  the  finger 
introduced  into  the  vagina  in  such  a  manner  as  to  turn  the  small 
growth  out  of  the  urethra.  They  vary  in  size  from  a  pin  head*  to 
that  of  a  nut.  The  most  important  point  of  implantation  is  the 
inferior  part  of  the  meatus.  Theii-  color  is  wine  red  or  violaceous. 
Under  pressm-e  they  become  pale  and  dimuiish  slightly  in  volume. 
Their  surface  is  smooth,  but  they  are  easily  excoriated  and  then 
bleed  profusely.  These  tumors  are  painful,  especially  so  at  the 
moment  of  micturition  or  of  coitus,  and  may  be  the  cause  of  a  form 
of  vaguiismus. 

Treatment. — The  simplest  treatment,  and  it  can  be  applied  mth- 
out  pain  after  painting  with  cocaine,  is  excision  followed  by  cauteri- 
zation with  the  thermo-cautery. 

Cancer  of  the  vulva. — Pathological  anatomy. — Primary  cancer 
of  the  vulva  is  rare.  Out  of  7,479  women  affected  with  cancer, 
Gurtl  has  noted  cancer  of  the  vulva  in  seventy-two  cases.  Cancer 
of  the  external  genitals  presents  several  histological  and  anatomi- 
cal forms.  From  a  histological  point  of  view  these  varieties  may 
be  distingi;ished :  epithelioma,  either  pavement  or  tubulated ;  sar- 
coma, and  its  variety  melano-sarcoma.  From  a  topographical  point 
of  view  we  may  make  two  different  varieties,  according  as  the 
neoplasm   develops  on  the   nymphae   and  cUtoris  (cancer  of  the 


Tumors  of  the  Vulva.  571 

vestibule),  or  as  it  arises  in  the  meatus  urinarius  and  extends  along 
the  urethra  (periurethral  cancer).  Epithelioma  offers  nothing  in 
particular  that  differs  from  that  described  under  cancer  of  the 
uterus.  Pure  sarcoma  of  the  vulva  may  occur,  but  most  frequently 
the  growth  affects  the  form  of  melano-sarcoma. 

^Etiology. — Cancer  of  the  vulva  is  most  frequent  between  the  ages 
of  forty  to  sixty.  But  it  has  been  seen  also  both  in  young  girls  and 
aged  women.  I  have  already  mentioned  the  predisposing  influence 
of  psoriasis.  Hutchinson  attaches  some  setiological  importance  to 
antecedent  syphilitic  lesions,  but  this  appears  doubtful. 

Symptoms. — Cancerous  nodules  may  long  remain  unnoticed  and 
pruritus  vulvae  constitute  the  first  symptom.  A  sero-sanguinolent 
discharge,  with  a  fetid  odor,  appears  as  soon  as  the  tumor  is  excori- 
ated. The  growth  at  first  resembles  a  wart,  the  size  of  a  little  nut, 
hard,  mammillated,  sessile,  or  a  little  pedunculated.  When  the 
nodules  are  multiple  or  confluent,  all  the  region  may  assume  a 
ligneous  consistency,  and  the  vaginal  orifice  may  be  somewhat 
retracted.  The  meatus  urinarius,  in  the  periurethral  form,  is  also 
more  or  less  occluded.  On  vaginal  examination,  the  urethra  is  felt 
as  a  hard  cord-like  body.  The  ulceration  which  occurs  has  uneven 
perpendicular  borders  covered  with  epidermoid  scales  or  crusts 
consisting  of  the  hardening  products  of  secretion.  In  the  vicinity 
the  skin  is  cedematous  and  has  the  aspect  and  the  consistency  of  an 
orange  peel.  The  secretion  from  the  ulcer  is  a  sanious  pus ;  haemor- 
rhages are  rare.  The  inguinal  glands  are  swollen  and  soon  show  a 
cancerous  cachexia.  Invasion  of  other  organs  may  occur,  or  death 
be  hastened  by  some  complication,  such  as  phlebitis  or  pleurisy. 
The  vagina,  the  rectum  and  the  bladder  are  invaded  by  extension  in 
the  latter  stages  of  the  disease.  The  pain  caused  by  the  proctitis 
or  the  cystitis  then  becomes  very  acute. 

Progress. — Prognosis. — The  latent  period,  or  that  of  simple  j)ru- 
ritus,  may  last  a  long  time.  But  as  soon  as  ulceration  begins  the 
disease  advances  rapidly.  In  melano-sarcoma  the  progress  is  not 
less  rapid.  In  general,  death  follows  at  the  end  of  two  or  three 
years.  Cases  where  the  patients  have  lived  ten  to  twenty  years  are 
of  doubtful  diagnosis. 

Treatment. — The  complete  extirpation  of  the  disease  is  the  only 
means  of  arresting  its  progress.  Thermo-cautery  has  been  advised 
for  this  purpose  to  avoid  haemorrhage.  But  operating  rapidly  with 
the  knife  and  scissors  and  the  aid  of  forci-pressure  the  blood  loss  is 
insignificant.  There  is  also  the  advantage  of  having  a  wound  that 
can  be  immediately  closed  with  sutures.  Care  will  be  taken  to 
restore  the  meatus  urinarius  by  a  perfect  coaptation  of  the  tissues. 

In  cases  where  ablation  cannot  be  made,  recourse  may  be  had  to 
palliatives.  They  are  especially  addressed  to  the  ichorous  dis- 
charge, the  fetid  odor  and  the  irritation  of  the  contiguous  parts. 


572  Inflammation  and  Cysts  of  the  Glands  of  Bartholin. 

Frequent  douches  with  antiseptic  and  disinfectant  sohitions  are 
used.  A  dressing  of  iodoform  gauze  is  introduced  into  the  ulcer- 
ations. Perhaps,  in  some  cases,  Kraske's  method  of  covering  the 
cancerous  ulcer  wth  healthy  skin  may  he  used  to  stay  their  progress 
and  to  alleviate  their  painful  symptoms. 


CHAPTER  XLVI. 


INFLAMMATION   AND   CYSTS   OF    THE    GLANDS 
OF  BARTHOLIN. 

^Etiology  and  general  ixitlmrjcny . — For  our  knowledge  of  the  path- 
ology of  these  glands  we  are  indebted  chiefly  to  Huguier.  Since 
then  little  has  been  added  to  his  descriptions,  but  it  has  been  con- 
ceded that  all  the  lesions  of  these  glands,  inflammations  or  cysts, 
have  one  and  the  same  origin,  blennorrhagia.  Suppuration  of  the 
excretory  canal  is  the  rule  in  vagmitis.  Its  orifice  is  surrounded 
by  a  red  areola  that  Sanger  calls  the  gonorrhoeal  macula.  To  cure 
this  inflammation  of  the  canal  it  should  be  incised  with  a  Weber 
lachrymal  knife  and  cauterized  with  a  pencil  of  nitrate  of  silver  or 
by  a  solution  of  chloride  of  zinc  (1-50). 

Intense  infection  causes  abscess  of  the  gland.  The  occlusion  or 
narrowing  of  the  excretory  canal  gives  rise  to  cysts. 

Cysts. — Symptoms. — The  sac  may  be  single  or  multiloeular.  Its 
form  is  ovoid,  it  is  rarely  transparent.  The  contents  are  ^-iscous, 
colorless  or  yellow,  sometimes  mixed  with  blood,  and  of  a  chocolate 
color.  The  size  varies  from  that  of  a  nut  to  that  of  a  goose  egg. 
The  tumor,  usually  unilateral,  most  frequently  on  the  left  side,  is 
elongated  in  the  axis  of  the  labium  of  which  it  occupies  the  pos- 
terior half,  nearer  the  mucosa  than  the  skin.  On  pressure,  it  is 
elastic  and  impressible  rather  than  fluctuating.  These  cysts  may 
be  to  some  extent  an  obstruction  to  walking  and  especially  to 
coitus.     They  have  a  marked  tendency  to  inflame  and  suppurate. 

Treatment. — -Evacuation  of  the  contents  of  the  cyst  is  not  suf- 
ficient, it  is  quicldy  reproduced  if  the  sac  is  not  destroyed  or  extu-- 
pated.  Numerous  procedures  have  been  proposed.  The  injection 
of  ten  to  twelve  drops  of  a  solution  of  zinc  chloride,  without  empty- 
ing the  cyst  and  after  aspiration  of  an  equal  quantity  of  its  contents, 
has  been  attended  with  success.  '  But  the  inflammation  tliis  causes 
may  be  very  severe  and  terminate  in  suppuration.  A  large  incision, 
followed  by  tamponing  with  iodoform  gauze  is  a  reliable  method 


Inflammation  and  Cysts  of  the  Glands  of  Bartholin.  573 

but  slow.  Extirpation  of  the  sac,  followed  by  immediate  reunion 
of  the  lips  of  the  wound  with  catgut  suture  in  superposed  rows, 
should  be  preferred.  My  method  is  as  follows  :  The  cyst  is  first 
punctured  with  a  trocar  and  evacuated.  It  is  then  washed  out  with 
hot  water  and  filled  with  melted  spermaceti  at  a  relatively  low 
temperature.  "When  the  sac  is  thus  distended  it  is  surrounded  with 
crushed  ice  and  at  the  end  of  a  few  minutes  a  hard  mass  is  ob- 
tained that  may  be  easily  and  quicldy  dissected  out,  with  simple 
anaesthesia  from  the  cold  and  from  injections  of  cocaine. 


Fig,  325. — Cyst  of  Bartholin's  gland  (a  sound  has  been  introduced  into  the  urethra). 

Abscess. — The  suppuration  of  a  gland  of  Bartholin  may  be 
primary  or  may  follow  inflammation  of  a  cyst.  The  swelling  and 
the  peripheral  oedema  are  considerable.  The  pain  is  severe  and 
lancinating.  There  is  always  a  certain  degree  of  fever  and  some- 
times retention  of  urine. 

To  this  acute  form  succeeds  a  chronic  inflammation  of  the  vulvo- 
vaginal gland.  This  is  a  very  distinct  clinical  form,  which  has 
been  described  by  Hamonie  and  Fauvel  as  an  obstinate  localized 
gonorrhoea.  There  are,  then,  no  inflammatory  signs,  properly  speak- 
ing, no  distinct  tumor,  but  a  simple  hypertrophic  inflammation  of 
the  gland  from  which  there  may  be  expressed,  by  pressure  on  the 
duct,  a  greenish  or  milky  pus.  • 

Treatment. — A  large  incision  of  the  sac  is  necessary  as  soon  as  the 
first  symptoms  of  inflammation  appear.  The  best  course  is  to  extirpate 
the  gland  at  once  from  the  base  of  the  wound,  excising  all  the  internal 
surface  of  the  sac  with  curved  scissors.  The  wound  is  then  washed 
out  with  a  strong  carbolic  solution  and  tamponed  with  iodoform 
gauze. 


674  Pruritus  Vulva. — Coccyfjodynia. 


CHAPTER  XLVII. 


PRURITUS   VULV-ffi.— COCCYGODYNIA. 

Pruritus  imlire. — The  sensation  of  itching,  of  burning,  which  ac- 
companies eruptions  of  the  \T.ilva,  or  its  irritation  by  the  abundant 
leucorrhoea  of  vaginitis,  of  metritis,  or  of  cancer,  or  even,  especiaUy 
in  children,  from  ascarides,  is  merely  a  symptom  and  not  a  disease. 
What  characterizes  the  vulvar  pruritus,  that  may  be  termed  idio- 
pathic, is  the  absence  of  any  lesion  that  could  explain  the  intoler- 
able smarting  Avhich  causes  patients  to  scratch  and  excoriate 
themselves. 

jEtiology. — In  the  absence  of  any  apparent  cause  some  authors 
have  invoked  a  central  origm.  The  arthritic  diathesis,  which  has 
been  arranged  by  Gueneau  de  Mussy,  does  not  cause  any  anatomi- 
cal modification  of  the  skin  appreciable  to  clinical  examination. 
Modifications  of  the  uterus  and  ovaries  appear  to  act  by  causing  a 
reflex  sensibility  of  the  vulva.  It  is  in  the  same  way  that  vesical 
calculi  cause  itching.  Diabetes  is  one  of  the  most  frequent  causes. 
Pregnancy  favors  the  appearance  of  pruritus. 

Symptoms. — The  pruriginous  sensation  may  be  continuous  or 
intermittent.  It  may  be  present  only  at  certain  times,  principally 
at  night  from  the  heat  of  the  bed.  Many  women  suffer  only  at  the 
menstrual  period.  The  patients  scratch  and  rub  themselves  and 
the  excoriations  become  a  new  source  of  smarting.  Profound  dis- 
turbances of  the  general  health  and  of  the  mental  condition  some- 
times results  from  the  excessive  irritation  of  the  nervous  system. 

Treatment. — Attention  should  first  be  directed  to  any  concomitant 
disease  that  may  have  an  influence  on  the  pruritus.  LoeaUy, 
eruptions  may  be  treated  if  they  exist.  Various  appUcations  have 
been  recommended  for  iodiopathic  pruritus.  Painting  the  surfaces 
with  cocaine  (1-10)  appears  to  succeed  best.  Slight  cauterization 
with  nitrate  of  silver  or  a  strong  carboUc  solution  have  also  been 
recommended.  Internally,  anti-spasmodies  maybe  given,  especially 
bromide  of  potassium  and  cannabis  indica.  Schroeder  and  Lohlein 
have  succeeded  by  excismg  portions  of  the  mucous  membrane  or  of 
the  skin  in  which  the  pruritus  was  localized. 

Coccygodynia. — Under  this  term  has  been  designated  an  intense 
locaUzed  pain  of  the  coccyx,  which  occurs  almost  exclusively  in 
women  and  which  is  often  associated  with  diseases  of  the  genital 
apparatus. 

Mtioloyy. —  In  the  majority  of  cases,  in  typical  cases  it  might  be 


Pruritus  Vulvce, — Goccygodynia.  575 

said,  there  is  no  appreciable  lesion  and  the  disease  appears  to  be  a 
true  neuralgia.  But  in  other  cases  a  concomitant  lesion  of  the 
uterus,  metritis,  deviations  or  prolapsus  of  the  ovary,  is  discovered. 
Though  these  lesions  may  not  be  sufficient  to  explain  the  locali- 
zation and  the  intensity  of  the  pain,  they  seem,  however,  to  be  con- 
nected with  its  origin  and  its  continuance.  Finally,  in  a  third  class 
of  cases,  there  exist  lesions  of  the  coccys  or  of  its  ligaments.  The 
influence  of  parturition  appears  beyond  doubt.  Though  influence 
of  lesions  of  the  coccyx  may  be  small,  we  cannot  refuse  to  admit 
them.  In  a  case  reported  by  Zweifel,  the  pain  was  apparently  due 
to  a  fall  wliich  had  probably  fractured  or  dislocated  the  bone. 
Beigel  has  observed  this  affection  in  young  children. 

Symptoms. — Pain  limited  to  the  coccyx  and  its  vicinity  is  the 
chief  symptom.  It  is  intense,  awakened  by  pressure,  by  movements 
of  rising  or  sitting,  by  walking,  by  defecation  and  by  coitus.  The 
pain  is  sometimes  so  intense  that  Scanzoni  compared  it  to  that  of 
dental  neuralgia.  Injuries  to  the  coccyx  may  be  detected  by 
examining  with  one  finger  in  the  rectum,  grasping  the  bone  between 
the  thumb  and  finger,  under  local  auffisthesia  with  cocaine. 

Treatment. — Successful  treatment  of  the  concomitant  diseases, 
especially  retroflexion,  is  sometimes  followed  by  subsidence  of  the 
pain.  Hypodermic  injections  of  cocaine  may  be  tried.  Injections 
of  morphine  and  belladonna  suppositories  are  also  of  service.  In 
absence  of  any  lesion  of  the  bone,  Grafe  recommends  electricity. 
In  inveterate  cases  relief  must  be  sought  in  surgical  measures  de- 
signed to  relieve  the  coccyx  from  the  action  of  the  attachee  muscles. 
Simpson  performed  myotomies  and  tenotomies  which  isolated  the 
bone  from  the  surrounding  parts.  The  best  method  is  the  extir- 
pation of  the  coccyx  first  practiced  by  Nott. 


676  Wounds  of  the  Vulva  and  Varjina. 


CHAPTER  XLVIII, 


WOUNDS  OF  VULVA  AND  VAGINA.— ACQUIRED 

ATRESIAS  AND  STENOSES.— FOREIGN 

BODIES. 


Wounds  of  the  vulva  and  vagina. — Jitiology. — Most  fre- 
quently wounds  of  the  ^nilva  or  vagina  are  due  to  the  fii-st  sexual 
approaches,  to  defloration,  or  to  parturition.  They  have  also  been 
observed  after  traumatisms.  In  rupture  of  the  hyraeu,  from  too 
forcible  coitus,  the  tear  may  extend  beyond  the  insertion  of  the 
membrane  toward  the  nympha^  or  the  vestibule.  The  vaginal  wall 
is  more  rarely  involved  than  the  \Tdva.  However,  eases  have  been 
reported  in  which  the  posterior  wall  of  the  canal  was  torn. 

Symptoms. — The  situation  and  the  extent  of  wounds  of  the  vagina 
and  vulva  vary  much  according  to  the  cause  which  produces  them. 
Hemorrhage  is  sometimes  troublesome  in  ruptures  of  the  hj-men. 
It  may  even  be  dangerous  to  life.  The  openiug  of  Douglas'  cul-de- 
sac  is  attended  ■with  prolapse  of  a  loop  of  intestines  which,  if  not 
reduced,  may  become  strangulated  and  gangrenous,  resulting  in  an 
ileo-vaginal  fistula,  should  the  patient  sur\ive  the  accident.  The 
opening  of  the  rectum  or  bladder  may  leave  a  fecal  or  a  urinary 
fistula. 

Treatment. — In  abnormal  narrowness  of  the  vagina  or  of  the  vulva 
prophylactic  treatment  should  be  instituted  during  pregnancy  or 
labor.  The  rupture  itself  should  be  treated  in  accordance  with 
ordinary  surgical  rules.  Haemorrhage  should  be  controlled  Ijy 
ligature,  forcipressure,  or  haemostatic  suture ;  the  lips  of  the  wound 
closed  after  reduction  of  the  prolapsed  parts,  and  aseptic  condition 
of  the  parts  maintained.  A  loose  tampon  of  iodoform  gauze  should 
be  placed  in  the  vagina  and  held  with  a  hght  ijressure  T-bandage. 

Acquired  stenoses  and  atresias. — .Etiology.  —  In  the 
immense  majoiity  of  cases,  narrowing  (stenosis)  or  obliteration 
(atresia)  of  the  vagina  or  of  the  vulva,  when  they  are  not  of  con- 
genital origin,  are  the  result  of  a  difficult  labor.  If  the  eschais 
which  result  involve  the  whole  thickness  of  the  wall  the  consequence 
is  a  fistula.  If  only  a  portion  of  the  thickness  of  the  wall  has 
necrosed,  the  cicatrix  which  remains  undergoes  retraction.  It  is 
also  possible  that  the  cicatrix  which  causes  the  stenosis  maybe  due 


Wounds  of-  the  Vulva  mid  Vagina.  577 

to  a  wound  from  a  foreign  body.     Cauterization,  gangrenous  slough 
during  an  infectious  disease,  esthiomene,  syphilitic  ulcerations  and 
pelvic  suppuration  are  recognized  causes  of  stenosis.  Senile  atrophy 
is  a  rare  cause. 

Symptoms. — The  disturbances  which  result  follow  slowly  and  are 
sometimes  long  retarded  by  the  constant  dilatation  produced  by 
conjugal  relations.  If  obliteration  is  complete,  the  menstrual  blood 
accumulates  above  the  obstacle  and  distends  the  vagina,  the  uterus 
and  even  the  tubes.  In  some  cases  the  patient  is  spared  these 
accidents  by  the  interruption  of  the  menstrual  function. 


Fig.  326. — Falciform  cicatricial  band  of  the  vagina  (Barnes). 

The  treatment  of  acquired  atresias  belongs  with  that  of  congenital 
atresias  and  will  be  considered  under  accidents  of  retention  resulting 
from  the  latter  form  of  malformation. 

Foreign  bodies. — The  most  diverse  foreign  bodies  have  been 
introduced  into  the  genital  canal.  It  is  sometimes  in  play  that  children 
introduce  objects,  but  most  frequently  the  body  has  been  used  for 
masturbation  and  has  escaped  from  the  fingers.  Some  foreign 
bodies  have  accidently  been  left  in  the  vagina,  such  as  broken 
canulas,  fragments  of  a  glass  speculum,  etc. 

If  the  object  is  smooth  and  not  porous  it  may  be  tolerated  a  long 
time.  However,  long-continued  pressure  on  the  same  point  ends 
in  ulceration  of  the  tissues.  If  the  object  is  porous,  its  infection 
determines  symptoms  of  suppurative  inflammation  or  of  progressive 
ulceration.  The  irritation  produced  around  the  foreign  body  may 
cause  an  annular  stricture  of  the  vagina.  Save  in  exceptional  cases, 
a  foreign  body,  even  when  tolerated,  causes  a  more  or  less  abundant 
leucorrhoea,  which  may  become  purulent  and  fetid  and  attended 
with  hfemorrhages. 


578  Malformations  of  the  Vulva  and  Hcrmaphrodism. 

The  treatment  consists  in  the  extraction  of  the  foreign  body  and 
in  the  cure  of  the  lesions  it  has  caused.  The  vaginal  cavity,  and  in 
particular  the  diverticula  which  lodged  the  foreign  body,  will 
require  antiseptic  cleansing  after  its  extraction.  The  resulting  me- 
tritis ■ftill  almost  always  require  treatment  by  curetting. 


CHAPTER  XLIX. 


MALFORMATIONS   OF    THE   VULVA  AND 
HERMAPHRODISM. 

Arrests  of  development. — Complete  atresia  of  the  vulva  and  of  the 
urethra  results  from  the  absence  of  fission  of  the  genital  tubercle. 
There  is  then  no  vulvar  opening.  According  as  the  cloaca  has  or 
has  not  been  divided,  the  rectum,  the  bladder  and  the  genital  canal 
are  separate  or  they  communicate  (Fig.  329, 1,2).  Chilcken  affected 
with  the  latter  deformity  are  usually  not  viable.  The  m-ethi-a  being 
absent,  the  bladder  and  the  genital  canal  are  distended  with  urine. 

The  absence  of  division  of  the  cloaca  is  sometimes  observed 
alone,  the  uro-genital  sinus  being  open  and  communicating  with 
the  rectiim,  which  does  not  terminate  in  the  anus  but  appears  to 
open  into  the  vagina.  This  has  been  called  ano-vulvar  atresia  or 
vestibular  and  ano-vagiual  atresia  (Fig.  328,  3). 

In  hypospadias  of  the  female  the  perinseum  has  taken  on  a  normal 
development  while  the  uro-genital  sinus  has  j)reserved  its  embiyonic 
condition  (Fig.  329,  4).  Hypospadias,  properly  so-called,  takes 
place  when  the  uro-genital  sinus  having  regularly  disajspeared,  the 
inferior  part  of  the  aUantois,  which  should  be  transformed  into  the 
urethi-a,  has  been  abnormally  included  in  the  formation  of  the 
bladder.  The  urethi-a  is  totally  absent  then,  and  the  vagina  and 
the  bladder  oi^en  together  into  the  vestibular  canal. 

Episj^adias  is  a  very  rare  malformation  in  the  female  and  its 
exact  origin  is  still  in  dispute.  It  may  coincide  with  exstrophy  of 
the  bladder  -n-ith  imperfect  union  of  the  symphysis  pubis,  as  well  as 
with  atresia  of  the  anus.  It  is  certaiuly  in  relation  vrith.  a  defective 
disposition  of  the  allantois.     A  bifid  chtoris  may  be  the  only  lesion. 

The  opening  of  the  ureter  into  the  viilva,  near  the  meatus,  con- 
stitutes a  very  rare  malformation,  but  it  is  of  gi-eat  interest  in 
consequence  of  the  congenital  incontinence  of  urine  that  it  causes. 

Total  absence  of  the  vulva  is  characterized  by  the  simple  opening 
of  the  utero-genital  sinus  at  the  vulvar  region  without  the  formation 


Malformations  of  the  Vulva  and  Hermaphrodism. 


579 


of  any  of  the  parts  that  belong  to  this  portion  of  the  genital  organs. 
May  this  anomaly  occur  with  normal  development  of  the  internal 
genital  organs  ?  Several  cases  are  to  be  found  in  the  older  writers, 
but  they  are  all  doubtful. 


Fig.  327. — Schema  of  the  development  of  the  genito-urinary  apparatus  (Henle).  I. 
Embryonic  state.  2.  Feminine  type.  3.  Male  type  (the  small  letters  of  Fig.  2  and 
Fig.  3  correspond  to  the  capital  letters  of  Fig.  l).  A,kidney;  B,  ureter;  C, bladder; 
D,  urachus;  E,  urethra;  F,  Wolffian  body;  G,  excretory  duct  of  the  Wolffian  body; 
H,  Miller's  canal;  I,  uterus ;  K,  seminal  glands  ;  L,  ligament  of  the  primitive  kidney ; 
M, uro-genital  sinus;  N,  genital  tubercle;  n  n,  cavernous  bodies;  o, genital  groove; 
P,  Bartholin's  glands. 

Absence  of  the  labia  majora  is  the  rule  in  exstrophy  of   the 
bladder.     It  may  be  observed  independently  of  any  other  anomaly. 


580 


Malformations  of  the  Vulva  and  Hermaphrodism. 


The  uymphae  may  also  be  missing  and  this  fact  is  often  associated 
with  imperfect  development  of  the  cUtoris.  Their  hyi^ertrophy  is 
much  more  common.  Sometimes  they  form  two  or  three  juxtaposed 
leaflets.  At  other  times  they  exceed  the  size  of  the  labia  majora 
and  project  outside  the  ATilva.  In  this  condition  they  form  what 
has  been  called  the  Hottentot  apron. 


Fig.  328. — Development  of  the  external  genital  organs.  Schematic  (Schroeder).  i. 
R,  rectum;  All,  allantois ;  M,  MuUer's  canal;  X,  beginning  of  the  vulva.  2.  The 
vulvar  depression  becomes  continuous  with  the  rectum  and  the  alL^ntois  forming  the 
cloaca,  CI.  3.  The  cloaca  is  divided  into  the  uro-genital  sinus  and  the  anus.  4.  The 
perinseum  is  completely  formed.     5.  The  urethra  and  the  vestibule  are  formed. 


Fig.  329. — Malformations  of  the  external  genital  organs.  Schematic  (Schroeder). 
I.  Complete  atresia  of  the  vulva.  Rectum,  r,  genit.1I  canal,  g,  and  bladder,  b,  com- 
municate. 2.  Complete  atresia.  The  allantois  is  separated  from  the  rectum.  3.  The 
perinceum  has  not  been  formed  and  the  cloaca  persists.  4.  Hypospadias  in  the  female, 
with  hypertropied  clitoris.     5-  Hypospadias  in  the  female. 

An  infantile  state  of  the  vulva  is  observed,  generally,  among 
feeble  subjects,  who  have  also  an  incomplete  development  of  the 
uterus  and  tubes. 

Hypertroi^hy  of  the  clitoris,  rare  in  our  chmate,  is  more  frequent 
in  the  tropical  regions.  It  may  then  give  rise  to  some  doubt  as  to 
the  sex  of  the  individual  where  it  coincides  with  apparent  occlusion 
of  the  genitals.  Hypertrophy  of  the  clitoris  has  been  observed  as 
an  accessory  malformation  in  other  anomaUes. 


Malformations  of  the  Vulva  and  Hermaphrodism. 


681 


Malformations  of  the  hymen. — Infantile  state. —  In  the  infant  at 
Lirtli  the  hymen  offers  a  great  development  and  its  three  parts  are 
very  distinct.  It  is  often  disposed  in  tlie  form  of  a  projecting  collar, 
especially  marked  helow.  But  the  usual  form  is  the  lahial  form 
(Brouardel).  This  form  may  persist  through  life.  There  may  be 
a  projection  of  the  posterior  part  of  the  left  lip  in  from  the  right, 
producing  an  interlacing  analogous  to  that  of  the  diaphragm. 

Anomalies  of  situation. — In  the  child  at  birth  the  hymen  is  situated 
deeper  than  in  later  years  and  this  fact  is  still  more  marked  in  the 
negro  race.  Abnormally,  the  hymen  in  the  adult  may  be  situated 
too  high  up.     Krimer  found  it  at  a  depth  of  two  centimetres. 

Anomalies  of  number. — Many  cases  have  been  reported  of  double 
hymen.  Some  are  only  membranous  occlusions  of  the  vagina  in 
the  new-born ;  others,  in  adults,  are  probably  in  many  cases  only  the 
vestiges  of  analogous  lesions  that  occurred  in  infancy  or  in  foetal  Hfe. 
There  may  also  be  seen,  as  I  shall  show  later,  an  anomaly  which 
reverts  toward  the  normal  disposition  in  many  animals. 


Fig.  330. — Infundibuliform  hymen  in  Fig.  331. — Debris  of  tlie  hymen  in  a 

the  new-born  foetus,     b,  band  of  tissue ;  parturient  female, 
mu,  meatus   urinarius;    h,  hymen;     ov, 
vulour  orifice. 

Anomalies  of  form. — The  hymen  is  called  circular  when  its  orifice 
is  wholly  central ;  semi-lunar,  when  it  approaches  the  superior 
border,  giving  the  membrane  the  form  of  a  crescent ;  falciform,  when 
the  orifice  is  so  great  that  it  leaves  only  a  narrow  fold.  Besides 
these  there  are  varieties  described  under  various  names  :  the  den- 
ticulate hymen,  the  linguliform  hymen,  the  infundibuliform  hymen, 
the  hymen  bifenestratus  and  the  cribiform  hymen. 

Anomalies  of  structure. — The  hymen  is  usually  thin,  membranous 
and  appears  to  consist  simply  of  two  lamellae  applied  against  each 
other  and  covered  on  their  free  surfaces  with  pavement  epithelium. 


682 


Malfornidtions  of  the  Vulva  and  Hermaphrodism. 


They  are  sometimes  fused,  sometimes  distinct.  The  variations  in 
struetiu-e  which  the  hymen  presents  are :  1.  A  great  thickness, 
producing  a  fleshy  appearance  without  increasing  its  tenacity;  2. 
Particular  rigidity,  giving  it  a  sclerous  consistency  that  sometimes 
demands  section  with  cutting  instruments ;  3.  Excessive  vascularity 
of  the  membrane  which,  in  some  cases,  has  been  the  cause  of  grave 
and  even  fatal  hsemorrhage  at  the  time  of  first  sexual  approach. 


Fig.  332. — Anomaly  of  the  hymen.     Fleshy  and  thick  hymen. 

Congenital  absence. — The  older  observations  on  the  total  alSsence 
of  the  hymen  are  of  doubtful  authority.  DeviUiere,  Tardieu  and  Brou- 
ardel  did  not  find  a  single  example  among  a  very  large  number  of 
childi-en  that  they  examined  for  the  purpose  of  a  medico-legal  study 
of  this  question. 

Hermaplirodisni. — The  term  true  hermaphrodism  implies  an 
anomaly  in  which  the  two  sexes  are  united  in  one  individual  and 
capable  of  their  full  functions.  I  will  discuss  the  so-called  cases 
of  true  hermaphi-odism  and  I  will  show  that  they  heve  never  been 
proven  to  exist.  But  the  appearance  of  double  sex  may  be  met 
iinder  various  circumstances,  in  consequence  of  malformations  of 
the  genital  organs,  which  have  been  arrested  in  their  embryonic 
stage  in  the  male,  or  have  developed  excessively  in  certain  por- 
tions in  the  female.  Individuals  of  the  first  class  are  iucomparably 
more  numerous  than  those  of  the  second,  and  the  great  majority 
of  pseudo  hermaphi'odites  that  have  been  described  have  belonged 


Malformations  of  the  Vulva  and  Herma'phrodism. 


583 


to  the  class  of  male  hypospadias.  The  criterion  for  the  determina- 
tion of  the  sex  in  complex  cases  is  furnished  by  the  presence  or  the 
absence  of  the  testicles  or  of  the  ovaries.  Tliis  constitutes  the  chief 
difficulty  under  certain  circumstances,  in  the  living,  owing  to  the 
impossibihty  of  judging  of  the  nature  of  the  genital  gland  when  it 
is  hidden  in  the  inguinal  canalor  in  the  abdomen. 


Fig.  333. — Vulva  and  vagina  open  on  the  side  in  a  foetus  of  eight  months,  ca, 
anterior  column ;  cp,  posterior  column ;  c,  clitoris ;  b,  masculine  band  of  the  vestibule; 
pi,  nymphse;  gl,  labia  niajora;   mu, meatus;   h,  hymen. 

To  present  a  comprehensive  view  of  hermaphrodism  we  may 
make  the  following  divisions,  more  from  a  practical  than  a  theo: 
retical  point  of  view:  1.  Partial  pseudo  hermaphrodism,  where 
there  are  certain  peculiarities  of  one  sex  with  evident  preponderance 
of  the  other.  This  class  includes  two  varieties,  gynandrous  and 
androgynous,  according  as  the  individual  belongs  to  the  female  or 
to  the  male  sex.  2.  Pseudo  hermaphrodism,  properly  so-called,  due 
to  perineo- scrotal  hypospadias,  where  the  external  genitals  have  an 
embryonic   arrangement,  and,  consequently  feminine.     Doubt  is 


584  Malformations  of  the  Vulva  and  Ilermaphrodism. 

removed  by  search  for  the  testicles.     3.   So-called   true  lierma- 
plu'odism. 

I.  Pariial  pseiido  hermaphrodism. — A.  Gynandrous.  —  The  ex- 
ternal organs  of  the  female  largely  simulate  those  of  the  male 
when  there  is  hypertrophy  of  the  clitoris  and  of  the  prepuce  with 
adhesion  of  the  labia  majora,  or  even  of  the  nymph?e  simulating  the 
scrotum  and  masldng  the  vaginal  orifice  (Fig.  334).  The  re- 
semblance is  still  more  marked  when  there  exists  at  the  anus  or  in 
the  labium  a  hernia  of  the  ovary.  This  hypertrophy  of  the  clitoris 
has  often  been  noted  in  women  addicted  to  onanism.  In  cases  of 
adhesion  of  the  labia  in  women  it  will  sometimes  be  possible  in  the 
new-born  to  destroy  it  by  traction  ^\'ith  the  fingers  or  ■nith  a  bliint 
instrument,  as  in  detachment  of  the  adherent  prepuce  in  phymosis. 


Fig.  334. — Partial  pseudo  hermaphrodistn  in  the  female,  with  h}'pertrophy 
of  the  clitoris. 

B.  Androgynous. — Indi%iduals  of  this  variety  are  cryptorchid  or 
monorehid  males  presenting  certain  external  characters  of  the 
female,  among  others  an  exaggerated  development  of  the  breasts. 
Here,  the  masculine  type  of  the  genital  organs  exists,  since  the 
scrotum  is  formed  and  is  sm-mounted  with  a  penis  having  a  per- 
forate glans.  But  the  absence  of  the  testicles  from  their  sacs,  the 
small  development  of  the  penis,  the  median  depression  of  the 
scrotum  which  simiilates  two  juxtaposed  labia  majora,  the  size  of 
the  breasts,  and  finally,  as  in  a  case  I  have  obseiwed  (Fig.  335),  the 
presence  of  vestiges  of  nymphse,  forming  a  crest  on  the  raphe,  give 
the  individual  feminine  aspect. 

II- — Pseudo  hcrmajjhrodism,  properly  so-called. — This  class  com- 
prises the  great  majority  of  cases  observed.  They  are  the  male  sex 
with  a  scrotal  hji^ospadias,  or  more  properly  periuseo-scrotal,  and 
numerous  autopsies  have  determined  their  exact  character.  I  have 
been  able  to  observe  thi-ee  cases,  in  the  hving,  and  all  thi-ee  were  of 
a  type  which  corresponded  with  the  descriptions  given  by  previous 
observers.  These  individuals  are,  as  a  general  rule,  regarded  at 
their  birth  as  females  and  are  dressed  and  educated  accordingly. 


Malformations  of  the  Vulva  and  Hermaphrodistn. 


585 


Fro.  335. — Partial  pseudo  hermaphrodism  in  the  male. 

Many  have  married.  In  such  eases  sexual  intercourse  has  nearly 
always  been  attempted  by  the  urethral  opening,  or  by  the  vulvar 
orifice.  At  the  same  time  some  have  had  a  fondness  for  women  and 
have  practiced  a  more  or  less  complete  coitus.  There  are  cases  in 
which  pseudo  menstruation  has  occurred  from  the  dilated  and 
irritated  urethi'a,  but  undeniable  examples  of  menstruation,  small 
in  quantity  and  periodic,  have  also  been  observed.  The  external 
conformation  of  the  genital  organs  resemble  those  of  an  embryo 
merely  enlarged.  The  penis  projects  but  slightly.  The  gland  has 
the  size  of  childhood  or  adolescence.  It  is  imperforate,  but  marked 
by  a  groove.  Below  is  found  a  vulvar  orifice  of  variable  dimensions, 
usually  very  narrow,  scarcely  sufficient  to  admit  the  finger.  A 
perfect  hymen  may  exist.  The  vagina  which  succeeds  to  the  vulva 
has  a  variable   depth,  even  as  much  as  ten  centimetres.     The 


586 


'Mnlfdrmntimis  of  the  Vulva  and  Hermaphrodism. 


prepuce  resemljles  the  hood  of  the  clitoris.  The  testicles,  which 
are  always  rudimentary  and  secrete  a  spermatic  fluid  incapable  of 
fecundation,  have  sometimes  descended,  at  other  times  they  are  in 
the  ring  or  in  the  abdomen. 


Fig.  336. — Pseudo  hermaphrodism,  with  perinaeo-scrotal  hypospadias. 
External  genitals  of  Julia  D.  (male).         ' 

The  development  of  the  breasts  is  often  feminine  as  well  as  the 
appearance  of  the  thighs  and  buttocks.  The  larjTix  projects  a  little 
and  the  voice  is  rather  feminine.  The  pelvis  is  masculine.  Usually, 
rectal  touch  combined  with  a  catheter  in  the  bladder  shows  the 
absence  of  all  traces  of  the  uterus  or  of  the  prostate.  Bimanual 
exploration  does  not  reveal  ovaries. 

III. — S()-c(dlcd  true  hermaj^hrodisni. — Though  admitted  ^^ithout 
hesitation  by  the  older  \\Titers  who  have  cited  numerous  probable 
cases,  true  hermaphrodism  is  to-day  disputed.  Klebs  has  made 
the  following  theoretical  classification  of  tiiie  hermaplirodism :  1. 
Bilateral,  where  the  ovary  and  testicle  exist  on  both  sides,  which 


Malformations  of  the  Vulva  and  Hermaphrodlsm.  587 


Fig.  337. — Pseudo  hermaphrodism,  with  perinseo-scrotal  hypospadias.  External 
genitals  of  Julia  D.  (male),  b,  musculine  band;  mu,  meatus  urinarius;  ov,  vulvar 
orifice. 


Fig.  341. — Pseudo  hermaphrodism,  vi-ith  pennseo  scrotal  hjpospadias 

(Zweifel).     Schematic  figure. 


688  Malformations  of  the  Vulva  and  Hermaphrodistn. 


.^-■S^^.v 


Fig.  33S. — Pseudo  hermaphrodism,  wilh  perinasoscrotal  hypospadias.  External 
genitals  of  Louise  B.  (male).  ^,  glans  ;  i,  musculine  band;  01/,  \Tilvar  orifice;  /ly, 
hymen ;  /,  fourchette ;  //,  nymphge ;  £/,  labia  majora. 

has  also  been  called  vertical  hermapkrodism.  2.  Unilateral,  with 
testicle  and  ovary  on  one  side  only.  3.  Lateral,  where  an  ovary 
exists  on  one  side  and  a  testicle  on  the  other  side.  The  first  two 
varieties  may  be  early  eliminated,  not  a  single  ease  of  unilateral 
hermaphi-odism  has  been  cited,  and  those  of  the  bilateral  variety 
are  still  more  doubtful.  As  to  cases  of  lateral  hermapkrodism 
autopsy  does  not  give  convincing  evidence  that  they  truly  have  the 
characteristics  of  both  sexes.  In  fact  there  does  not  really  exist  a 
single  weU-proven  case  of  true  hermaphi'odism — of  the  co-existence 
of  ovaries  and  testicles  in  the  human  race.  This  anomaly  does  not 
seem  impossible,  however,  a  jmori.  This  disposition  is  fi'equent 
among  fishes  and  the  batrachians.    But  it  appears  rare  among  the 


Malformations  of  the  Vulva  and  Hermaphrodism. 


589 


superior  vertebrates.  Hermaphrodism  has  been  found,  however, 
among  goats  and  the  toads.  Hypospadias,  with  pseudo  hermaphro- 
dism, has  been  more  frequently  observed. 


'!■' 


ki 


Fig.  339.  —  Pseudo  hermaphrodism. 
Genitals  of  Julia  D.  (male).  Seen  with 
thighs  separated. 


Fig.  340. — Details  of  the  hymen  in  the 
same  subject.  ^,  glans;  ^/,  labia  majora; 
mu,  meatus  urinarius ;  //,  nymphas ;  ov,  vul- 
var orifice ;  hy,  hymen ;  f,  fourchette. 


Treatment. — The  different  malformations  that  I  have  enumerated 
are,  for  the  most  part,  more  interesting  to  the  anatomist  than  to 
the  surgeon,  and  active  interference  is  rarely  called  for.  Adhesion 
of  the  labia  may  be  separated  by  tearing,  and,  if  necessary,  by 
incision.  Hypertrophy  of  the  labia  and  of  the  clitoris  may  call  for 
amputation  of  the  exuberant  portions,  especially  if  the  irritation 
produced  by  contact  with  the  clothing  is  painful.  In  epispadias  the 
parts  may  be  sutured  after  a  denudation  siiitable  to  the  form  and 
dimensions  of  the  fissure.  Malformations  of  the  hymen  may  de- 
mand excisions  or  partial  resection. 


590  Mal/orinatiuiis  of  the  Vulva  and  of  tite  Vayina. 


CHAPTER  L. 


MALFORMATIONS   OF   THE   VAGINA  AND   OF 
THE    UTERUS. 

To  give  a  clearer  eomprebensiou  of  the  malformations  which  result 
from  an  arrest  of  development,  we  may  make,  with  Furst,  live 
divisions  of  the  embryonic  period. 

1.  Period  from  fecundation  to  the  eighth,  week. — This  comprises  the 
epoch  wliich  can  be  considered  the  indifferent  period,  where  the 
tendency  toward  one  or  the  other  sex  is  not  yet  marked  by  the 
atrophy  of  Muller's  canals  or  of  the  Wolffian  bodies.  The  canals 
of  Muller  are  adherent  and  separated  by  a  septum.  There  exists 
a  cloaca  into  which  the  intestine  and  the  urachus  open.  The  genital 
tubercle  and  the  genital  fissure  are  also  without  any  marks  of  sexual 
differentiation. 

2.  Period  from  the  eighth  to  the  twelfth  iveek. — At  the  end  of  this  time 
the  septum  of  the  genital  canal  has  wholly  disappeared ;  the  fusion 
of  Muller's  canals  is  prolonged  above ;  the  insertion  of  the  round 
ligament  clearly  separates  that  which  Anil  be  the  tube  above  from 
that  which  will  be  the  uterine  comu  below.  It  is  at  the  end  of  this 
period  that  the  cloaca  is  divided  into  the  anal  portion  and  the  uro- 
genital portion. 

3.  Period  from  the  twelfth  to  the  twentieth  week. — The  uterine 
cornu  are  fused,  the  arbor  vitfe  has  appeared  in  the  cavity  of  the 
uterus,  while  the  vagina  is  still  smooth.  The  cerA"ix  uteri  is  formed. 
The  permseum  is  enlarged.  While  the  vagina  develops,  the  uro- 
genital sinus  remains  stationary,  becoming  accessory,  so  that  the 
bladder  now  appears  to  open  into  the  genital  canal.  The  m-o-genital 
sinus  is,  henceforth,  the  vestibule  of  the  vagina.  The  genital 
tubercle  is  reduced  to  the  proportions  of  the  clitoris,  the  edges  of 
the  genital  fissure  have  formed  the  nymphs. 

4.  Period  from  the  twentieth  week  to  the  end  of  the  fa'tal  period. — 
This  is  marked  by  the  formation  of  folds  in  the  vaginal  mucosa,  and 
by  the  development  of  the  fundus  of  the  uterus. 

•  5.  Period  from  birth  to  pnbcrti/. — The  utenis  increases  a  httle  in 
tliickness ;  toward  the  sixth  year,  the  uterine  mucosa,  which  until 
then  was  plaited,  becomes  smooth,  and  there  remains  only  a  single 
A'ertical  fold. 

Aitiolugii — Pathogeny. — Malformations  of  all  these  organs  have 
long  been  considered  as  simple  freaks  of  nature.  What  is  the 
initial  cause  of  anomalies  of  the  genital  organs  ?    Must  we   rest 


Malformations  of  the  Vulva  and  of  the  Vagina.  591 

content  with  the  theory  of  arrest  of  development,  or  can  we  go 
further  to  a  superior  cause,  atavism,  for  example,  reproducing 
sporadically  in  one  species  the  forms  of  another  species,  by  the 
effect  of  what  Darwin  has  called  a  ijhenomenon  of  reversions  ?  I 
merely  allude  to  this  theory  without  undertaking  to  discuss  it.  The 
predisposing  causes  are  often  obscure.  It  is  not  to  be  doubted  that 
heredity  frequently  has  an  influence. 

The  immediate  cause,  the  anatomical  condition  of  the  mal- 
formation, is,  in  the  immense  majority  of  cases,  a  simple  arrest  of 
morphological  involution  or  in  the  organic  growth.  It  is  important 
to  make  a  clear  distinction  between  these  two  classes  of  facts.  In 
the  first,  the  organ,  while  having  a  fcetal  type,  may  have  adult 
dimensions.  In  the  second,  which  may  exist  alone  or  in  combination 
with  the  first,  the  organ  ha\'ing  the  adult  type  has  been  attacked 
by  aplasia ;  it  has  remained  smaller  in  totality  or  in  certain  of  its 
parts.  Finally,  there  are  some  facts  wliich  appear  to  be  explamed 
only  by  a  true  pathological  process  taking  place  during  fcetal  life 
and  producing  adhesions. 

Malformations  of  the  uterus  and  of  the  vagina  frequently  appear 
together.  Thus  there  is  observed  a  complete  simultaneous  absence 
of  one  of  the  segments  of  the  genital  canal  with  rudimentary  de- 
velopment of  the  other.  However,  as  these  anomalies  may  also 
exist  separately,  there  is  a  true  clinical  interest  observed  in  de- 
scribing in  separate  chapters  the  vices  of  development  of  the  vagina 
and  those  of  the  uterus. 

Malformations  of  the  vagina.  —  Com-plete  absence  and 
rudimentary  develo2)meRt. — Patliological  anatomy  and  symptoms. — 
Anatomically,  there  is  a  radical  difference  between  these  two  varie- 
ties; in  a  ehnical  point  of  view,  none.  In  comjDlete  absence,  there 
is  no  trace  of  vaginal  tissue  between  the  bladder  and  the  rectum ; 
in  rudimentary  development,  there  are  fibrous  tracts  of  connective 
tissue  in  the  place  which  the  vagina  should  occupy.  The  uterus 
■  may  be  totally  absent,  or  be  reduced  to  a  rudimentary  body.  In 
other  cases  it  is  normal ;  the  ovaries  exist,  but  there  is  no  menstrual 
molimen.  More  exceptionally,  there  are  periodical  pains  at  the 
moment  of  o\ailation.  The  vulva  has  also  been  absent,  in  some 
cases,  at  the  same  time  as  the  vagina. 

Eectal  exploration,  associated  with  a  sound  in  the  bladder,  or 
even  with  vesical  touch,  should  always  be  practiced.  Tire  fibrous 
cord,  which  exists  in  cases  of  rudimentary  development,  is  thus 
perceived,  and  it  may  be  valuable  as  a  guide  during  operation.  In 
cases  of  absence,  or  of  a  rudimentary  state  of  the  uterus,  a  sound 
m  the  bladder  may  be  detected  by  rectal  touch,  not  only  below  but 
also  very  high  up.  The  ovaries  will  be  sought  with  care  by  rectal 
exploration  combined  with  abdominal  palpation.  This  examination 
should  always  be  made  under  anaesthesia. 


592 


Malformations  of  the  Vulva  and  of  the  Vayina. 


Treatment. — The  absence  of  a  part  or  the  whole  of  the  vagina 
gives  rise  to  very  different  therapeutic  indications,  according  to  the 
state  of  the  uterus.  If  this  organ  is  ■nell  developed,  symptoms  of 
hstmatometra  appear  at  puberty,  necessitating  an  operation,  which 
I  Avill  describe  later.  If  there  is  no  uterus,  but  only  well  developed 
ovaries,  dysmenorrhceal  pains  may  give  rise  to  the  necessity  for 
castration.  There  remain  cases  in  which  there  is  only  a  deformity 
and  a  sexual  incompetence,  and  where  the  patient  demands  that  an 
artificial  vagina  be  provided  solely  for  the  pui-pose  of  coitus. 


Fig.  342. — Absence  of  the  vagina  and  uterus,  with  well-developed  hymen. 

I.  If  an  artificial  vagina  is  decided  on,  the  rectum  must  be  de- 
tached with  great  care,  beginning  at  the  bottom  of  the  Milvar 
depression,  proceeding  step  by  step,  by  combined  dissection  and 
tearing.  As  soon  as  the  excavation  is  of  sufficient  depth,  about 
six  to  eight  centimetres,  the  base  of  the  iufundibulum  thus  created 
must  be  covered  by  transposing  the  skin  and  mucous  membrane  of 
the  contiguous  parts.     After  suture,  the  artificial  canal  should  be 


Malformations  of  the  Vulva  and  of  the  Vagina.  593 

packed  with  iodoform  gauze  and  the  tamponnemeut  continued  until 
cicatrization  is  complete. 

II.  The  unilateral  vagina. — It  is  probable  that  in  many  cases, 
without  the  anomaly  becoming  apparent,  a  single  canal  of  Muller 
has  served  to  form  the  vagina.  This  occurs  without  doubt  in  some 
eases  of  uterus  unicornis.  This  fact  may  be  suspected  from  the 
narrowness  of  the  canal.  Cases  of  partial  duplicity  of  the  vagina 
owe  their  origin  to  incomplete  development  of  one  of  MuUer's  canals, 
and  the  vagina  is  partially  unilateral,  but  it  is  more  natural  to  place 
these  cases  in  the  following  class  : 

III.  Double  vagina. — When  the  septum  divides  the  entire  vagina 
the  uterus  is  also  double.  The  septum  is  not  generally  placed  in 
the  center  of  the  organ,  so  that  one  of  the  canals  is  found  a  little 
in  front  of  the  other.  Coitus  takes  place  through  one  canal  at  the 
expense  of  the  other. 

Atresia  vaginae  lateralis  is  due  to  the  fact  that  one  of  Muller's 
canals  suffers  arrest  of  development  at  a  rudimentary  stage.  It 
thus  constitutes  a  pocket  which  may  remain  unnoticed  until  it  fills 
with  blood  at  puberty,  or  with  pus  in  consequence  of  infection. 

IV.  Atresia  and  congenital  stenosis.  —  Transverse  hands. — The 
history  of  atresia  of  the  vagina  is  confounded,  in  an  anatomical 
point  of  view,  with  that  of  imperforate  hymen  and  of  the  absence 
and  rudimentary  development  of  the  vagina,  which  have  already 
been  considered.  Stenosis  of  congenital  origin  when  it  presents 
under  the  form  of  partial  adhesion  and  transverse  bands,  is  due, 
without  doubt,  to  the  partial  persistence  of  the  adhesion  which 
unites  the  vaginal  walls  at  a  certain  period  of  embryonic  life. 

The  obstacle  to  coitus  and  to  delivery  often  necessitates  operative 
treatment. 

Malformations  of  the  uterus. — I.  Absence  of  the  uterus — 
Rudimentary  develojmient. — These  two  malformations  deserve  to  be 
considered  jointly,  for  the  differences  which  distinguish  them  have 
no  cHnical  importance.  In  both  cases  the  organ  is  practically 
wanting,  whether  there  is  no  trace  at  all  of  a  uterus,  or  merely  an 
msignificant  vestige.  Complete  absence  is  extremely  rare,  and 
many  cases  that  have  been  reported  are  errors  of  interpretation.  In  ' 
several  autopsies  rudimentary  uterine  cornua  appear  to  have  been 
taken  for  tubes.  The  exact  insertion  of  the  round  ligaments  is  an 
important  landmark.  In  complete  absence  of  the  uterus  the  rectum 
and  the  bladder  touch,  and  the  round  ligaments  also  are  lost  in  the 
connective  tissue  between  these  two  organs'. 

A  rudimentary  uterus  presents  itself  to  the  examining  fingers  as 
a  small  mass  of  variable  form,  occupying  the  place  in  which  the 
organ  is  normally  found.  In  extreme  cases,  there  is  only  a  slight 
thickening  of  the  posterior  wall  of  the  bladder,  or  a  fibro-muscular 


594 


Malformations  of  the  Vulva  and  of  the  Vagina. 


structure  simply  reinforcing  the  broad  ligament  (Langeubeck) ;  or, 
again,  a  band  stretching  between  the  two  tubes  (Nega).  Taken  to- 
gether with  the  cervix,  it  forms  a  T,  and  is  termed  a  uterus  lijjartitus. 
OMilation  occurs  in  such  cases,  but  it  does  not  cause  molimen  as 
a  general  rule,  and  there  is  no  menstruation. 


Fig.  343. — Rudimentary  uterus  (I.  Veil).    U,  uterus,  without  cavity ;  h,  rudimentary 
comu;  O,  ovary;  T,  tube;  r,  round  ligament. 


Fig.  344. — Rudimentary  uterus  of  the  variety  bipartitus  (Rokitansky). 


II.  Uterus  unieomis.— The  uteinis  is  developed  at  the  expense  of 
a  single  one  of  MuUer's  canals,  the  other  being  atrophied.  The 
portion  above  the  cervix  is  elongated,  narrow,  and  curved  toward 
the  tube,  with  which  it  is  with  it  continuous,  and  of  which  it  con- 
stitutes only  an  inferior  expansion.  An  important  variety  is 
characterized  by  the  presence  of  a  rudimentary  cornu.  When  the 
uterus  unicornis  becomes  an  adult  organ  it  takes  on  the  functions 
of  a  normal  \iterus.  Menstruation  is  regular.  Pregnancy  goes  on 
without  disturbance  in  the  large  cornu.  But  if  the  ovum  is  lodged 
in  the  rudimentary  cornu,  rupture  of  its  walls  takes  place  between 
the  third  and  the  sixth  mouth. 

III.  Double  uterus. — The  uterus  is  reaUy  double  when  Muller's 
canals  are  not  fused,  or  when  they  are  only  partially  united,  each 
taking  a  complete  development.  There  are  several  varieties  of 
double  uterus : 

1.  A  uterus  bicornis  is  one  in  which  the  two  halves  of  the  uterus 
are  separate  from  each  other.  If  the  division  extends  to  the  cervix, 
there  is  a  uterus  bicornis  duplex  or  septus.  When  the  cervix  does 
not  present  any  trace  of  division,  we  have  a  uterus  bicornis  unicollis. 
Finally,  the  union  of  the  two  segments  may  be  almost  complete 


Malformations  of  the  Vulva  and  of  the  Vagina.  595 

and  tbe  bifid  character  manifested  only  by  a  depression  in  the 
fundus  of  the  organ,  resulting  in  a  uterus  arcuatus. 


Fig.  345. — Schematic  figure  of  an  infantile  uterus,  left  unicornis  variety  (P.  MuUer). 
a,  cervical  portion;  b,  body;  c  d,  longitudinal  axis  of  the  foetus;  e,  summit  of  the 
uterine  cavity;  f,  tube;  g,  ovary;  h,  ovarian  ligament;  i,  round  ligament;  k, 
parovarium. 


Fig.  346. — Uterus  unicornis  (Schroeder). 

Menstruation  in  uterus  bicornis,  with  equal  development  of  both 
segments,  may  occur  from  both  sides.  In  pregnancy  menstruation 
sometimes  takes  place  from  the  opposite  side.  Pregnancy  may 
follow  a  regular  course.  The  vacant  half  of  the  uterus  hypertro- 
phies at  the  same  time,  and  the  expulsion  of  a  decidua,  has  been 
observed.     During  labor,  both  cornua  contract. 

2.  Uterus  bilocularis. — The  characteristic  feature  of  tliis  mal- 
formation consists  in  a  normal  configuration  of  the  uterus  externally, 
while  the  cavity  is  separated  into  two  parts  by  a  median  septum. 
What  has  been  said  of  uterus  bicornis,  relative  to  menstruation  and 
pregnancy,  applies  equally  in  this  case. 

3.  Uterus  duplex. — In  this  case  there  are  two  organs  entirely 
separate.    Each  segment  has  almost  the  appearance  of  a  complete 


596 


Malfm-mations  of  the  Vulva  and  of  tlie  Vagina. 


uterus.  For  a  long  time  it  was  believed  that  this  malformation 
occurred  only  in  the  non-viable  fcetus.  Cases  observed  in  the 
adult,  are  all  of  recent  date.  It  is  often  difficult,  in  clinical  exami- 
nation, to  decide  between  a  complete  uterus  hicomis  and  a  uterus 
duplex.  The  atresia  of  one  of  the  segments  may  produce  lateral 
haematometra.  Pregnancy  may  occur  in  both  cavities  simul- 
taneously. 


Fig.  348. — Uterus  bicomis  unicervical  (Barnes). 


Malformations  of  the  Vulva  and  of  the  Vagina. 


597 


Fig.  349. — Uterus  bicornis  (Barnes). 


Fig.  350. — Uterus  bilocularis  and  double  Fig  351  — Uterus  didelphys  and  double 
vagina  (Kussmaul).  vagina  (Olivier),    a,  right  segment ;  b,  left 

segment ;  c  d,  right  ovary  and  round  liga- 
ment; gj,  left  vagina  and  cervix ;  k,  septum 
between  the  two  vaginas ;  h  i,  right  vagina 
and  cervix. 

4.  Foital  or  infantile  uterus.  —  In  this  anomaly,  completely  de- 
veloped, the  uterus  is  iii  its  general  form,  but  remains  stationary 
in  point  of  growth,  preserving  the  proportions  and  almost  the  same 


598 


Malformations  of  the  Vulra  and  of  the  Vaf/ina. 


dimensions  it  had  at  birth.  A  somewhat  subtile  difference  has 
been  established  between  fcetal  uterus,  which  represents  the  last 
stage  of  its  evolution  during  embryonic  life,  and  infantile  uterus, 
in  which  the  uterus  presents  the  type  of  the  new-ljorn  child. 
What  characterizes  both  is  the  disproportion  between 
the  cervix  and  the  body  of  the  uterus,  corresponding 
to  the  fcetal  type.  The  cervix  is  two  or  thi'ee  times  as 
long  as  the  body,  and  while  its  walls  are  relatively 
thick,  those  of  the  body  are  tliin  and  sometimes  mem- 
braneous. The  total  length  of  the  uterine  cavity 
does  not  exceed  four  centimetres.  The  cervix  is  small, 
has  a  narrow  orifice,  and  is  conical  in  form  or  slightly 
taperoid.  The  vagina  is  usually  short  and  narrow. 
The  external  genitals  are  sometimes  of  small  develop- 
ment. The  breasts  are  small.  There  is  complete 
amenorrhoea. 


Fig.  353. — Congenital  obliquity  of  the  uterus.     Incomplete  development 
of  the  right  side  (Tiedemann). 

Congenital  obliquity  and  latero-position  of  the  litems  are  due  to  an 
asymmetry  in  the  development  of  the  nterus.  One-half  of  the  organ 
predominates,  causing  distortion  and  inchning  the  cervix  to  the 
most  developed  side. 

Dupliciti/  of  the  external  orifice  of  the  cervijc. — A  double  orifice  of 
the  cervix  may  exist  in  the  absence  of  any  other  septum  of  the 
genital  canal.  This  anomaly  has  caused  accidents  during  delivery, 
but  most  frequently  it  is  pushed  aside  or  torn. 


Accidents  of  Retention  Consecutive  to  Genital  Atresias.        599 


CHAPTER  LI. 


ACCIDENTS    OF   RETENTION    CONSECUTIVE    TO 
GENITAL  ATRESIAS. 

jEtiology  and  symptoms.— 1  have  alluded  to  those  conditions  in 
wliich  the  genital  canal  may  be  found  closed  at  different  points, 
from  the  hymen  to  the  retracted  portion  of  a  rudimentary  cornu. 
This  occlusion,  it  has  been  seen,  may  completely  obstruct  the 
canal ;  may  close  entirely  one  of  the  halves  proceeding  from  its 
division,  or  may  isolate  only  a  diverticulum  that  arises  from  a  faulty 
conformation  of  the  parts.  At  puberty,  if  the  condition  of  the 
ovaries  and  of  the  tubo-uterine  mucosa  is  such  as  to  permit  the 
occurrence  of  menstrual  phenomena,  the  exuded  blood  finds  no 
exit.     It  then  accumulates  in  the  closed  space  and  distends  it. 

Hcematocolpus  occurs  when  the  hymen  or  the  inferior  portion  of 
the  vagina  is  imperforate  in  the  form  of  a  tumor  which  compresses 
the  rectum  and  the  bladder  and  bulges  out  the  membrane  that 
limits  it  on  the  vulvar  side.  The  uterus  is  pushed  upward.  Only 
the  cavity  of  the  cervix  is  distended  at  first,  while  the  body  of  the 
uterus  resists  a  long  time.  Bimanual  exploration  with  rectal  touch 
detects  fluctuation.  The  small  hard  mass  that  surrounds  the 
tumor,  and  which  is  the  non-dilated  body  of  the  uterus,  often 
causes  doubt  in  the  diagnosis  (Fig.  354).  When  the  inferior  part 
of  the  vagina  is  wanting,  the  hsematocolpus  is  limited  to  the  re- 
maining portion  of  the  canal  and  to  the  cervix. 

For  the  production  of  haematometra  the  cavity  of  the  uterus  is 
the  seat  of  accumulation.  This  occurs  when  the  whole  of  the  vagina 
is  absent  or  when  there  is  an  atresia  of  the  cervix.  Then  the  whole 
uterus  is  transformed  into  a  sac,  usuaUy  with  thick  walls,  rarely 
with  thin,  in  which  the  cervix  and  the  body  are  blended.  If  the 
atresia  occurs  at  the  internal  orifice,  only  the  body  is  distended 
(Fig.  355).  In  all  cases  of  haematometra  and  in  many  cases  of 
hssmatocolpus  the  tubes  are  dilated  by  an  hsematosalprnx.  The 
blood  which  accumulates  in  the  tubes  does  not  come  from  the 
uterus.  The  tubal  tumor  may  acquire  large  proportions.  Some- 
times a  small  quantity  of  blood  filters  through  the  closed  abdominal 
orifice  and  then  slight  attacks  of  perimetro-salpingitis  occur.  If 
the  blood  is  effused  into  the  abdomen  in  great  abundance  we  have  a 
pelvic  hsematocele. 

The  contents  of  these  diverse  sacs  formed  by  the  retention  of  the 
menses  is  a  thick  blood,  of  chocolate  color  and  syrupy  consistence. 


600        Accidents  of  Retention  Consecutive  to  Genital  Atresias. 

After  puncture,  for  the  purpose  of  evacuation,  the  sac  lias  been  seen 
to  suppurate  and  become  transformed  into  pyocolpus  or  pyometra. 
The  decomposition  of  the  fluid  may  also  cause  physometra. 

Besides  the  appearance  of  the  tumor,  Mhich  begins  at  puberty  and 
increases  progi-essively,  pain  is  observed  at  the  menstrual  period 
in  the  form  of  colic  that  may  be  attributed  as  much  to  the  distention 
as  to  the  escape  of  a  small  quantity  of  blood  into  the  peritoneum. 
The  formation  of  an  hamatometra  may  be  prevented  by  vicarious 
menstruation. 


Fig.  354. — Haematocolpus  from  atresia  Fig.  355. — Hsematometra  from  obliter- 
of  the  hymen  (Schroeder).  ation  of  the  internal  os  of  the  cervix. 

Diagnosis. — The  absence  of  the  menses,  the  imperforation  that  is 
usually  accessible  to  examination,  the  appearance  of  a  tumor 
occupying  the  genital  cavities,  are  the  symptoms  which,  taken 
together,  are  pathognomonic.  Care  should  be  used  iu  the  explo- 
ration of  uterine  and  tubal  tumors  not  to  employ  too  much  force 
iu  seeking  fluctuation,  for  fear  of  mptui-e.  In  cases  of  total  or 
partial  division  of  the  genital  canal,  the  diagnosis  of  lateral  ha?mato- 
colpus  or  lateral  haematometra  is  especially  diflicult.  The  tumor 
of  hsematocolpus  does  not  exactly  follow  the  dii-ection  of  the  per- 
meable side  of  the  vagina,  but  in  consequence  of  an  evolution  it 
desei-ibes  a  semi-hemisphere  around  it.  Above,  the  tumor,  which 
is  fluctuatiug  and  cylindi-ical,  is  capped  by  the  corresponding  uterine 
cornu.  The  diagnosis  is  very  difficult  when,  with  a  divided  vagina, 
the  accumulation  of  blood  is  situated  in  a  segment  of  the  uterus, 
bicornis,  bilocularis,  or  duplex.  The  relations  of  the  tumor  should 
be  carefully  sought  by  bimanual  exploration,  searchuig  for  the  un- 
dilated  segment  which  is  displaced  laterally. 

Prognosis. — Left  alone,  the  sanguineous  collections  resulting  from 
the  gynatresias  are  of  very  grave  prognosis.  Spontaneous  evacu- 
ation does  not  result  in  cure  but  ordy  in  temporary  relief,  followed 


Accidents  of  Retention  Consecutive  to  Genital  Atresias.        601 

later  by  symptoms  of  retention  often  aggravated  by  suppuration. 
In  fact,  spontaneous  perforation  is  always  insufficient  and  closes 
again  after  having  permitted  evacuation,  but  also  infection  of  its 
sac. 


Fig.  356 — Haematocolpus  and  haematometra  from  atresia  of  the  lower 
part  of  the  vagina  (Barnes). 

In  gynatresias  of  a  segment  of  the  divided  genital  canal  the  prog- 
nosis is  less  grave.  Lateral  haematocolpus  is  frequently  terminated 
by  rupture  into  the  permeable  part  of  the  canal.  But  suppuration 
generaUy  attacks  the  cavity  and  causes  a  pyocolpus  which  empties 
and  refills  alternately  and  may  give  rise  to  grave  accidents,  if  the 
perforation  is  not  converted  artificially  into  a  large  opening.  In 
partial  haematometras  of  a  rudimentary  cornu,  the  sanguineous 
exudation  may  cease  and  the  tumor  remain  stationary. 

Before  the  antiseptic  period,  the  opening  of  these  large  collections 
very  frequently  caused  septicaemia  and  operative  interference  was 
in  disrepute.  To-day  very  numerous  successful  cases  have  demon- 
strated the  safety  of  this  procedure  if  it  is  carried  out  boldly  and 
■with  antiseptic  precautions.  In  consequence  its  therapeutic  prog- 
nosis is  radically  changed. 

Treatment. — 1.   Total  hamatocolpus  and  partial  hcEmatometra  {cervi- 


602        Accidents  of  Retention  Consecutive  to  Genital  Atresias. 

ral). — {Ily menial  or  retro-hymenial  atresia).  —  Simple  puncture  or 
aspiration,  not  followed  by  incision  at  the  same  sitting,  though  it 
appears  a  safe  operation,  is,  in  reality,  a  dangerous  one.  It  is 
liable  to  he  followed  by  suppuration.  It  is  necessary  then  to 
commence  by  a  slow  evacuation  with  a  small  incision,  a  simple 
puncture  with  the  knife,  thus  permitting  the  liquid  to  flow  slowly, 
from  a  quarter  of  an  hour  to  an  hour.  Then  the  oi'ifice  is  immedi- 
ately enlarged  by  a  cruciform  incision.  It  is  more  harmful  than 
useful  to  excise  the  obdurator  membrane  at  the  same  time. 
Cleansing  of  the  sac  should  be  accompUshed  by  antiseptic  uijections 
of  moderate  force.  The  operation  is  completed  by  lightly  packing 
the  vagina  'sdth  iodoform  gauze. 

Partial  hcematocolpus  and  partial  or  total  ]t<xniatometra. — {.-itresia  of 
a  great  jjart  or  of  the  irholc  of  the  vagina). — It  is  then  necessary  to 
proceed  to  a  true  dissection,  which  is  very  dangerous  from  the  con- 
tiguity of  the  rectum  and  bladder.  I  have  ah-eady  described  the 
beginning  of  this  operation  when  it  aimed  only  at  the  establishment 
of  a  canal  for  coition,  in  the  absence  of  the  uterus.  When  there  is 
an  hsematometra  the  presence  of  the  tumor  serves  as  a  valuable 
guide  during  the  dissection.  As  soon  as  its  immediate  vicinity  is 
reached  a  trocar  is  pushed  in  the  direction  of  the  fluctuating  point. 
When  the  sac  is  thus  penetrated  it  is  incised  in  small  snips  with  a 
narrow-bladed  knife  along  the  side  of  the  canula.  The  calibre  of  the 
canal  must  be  maintained  afterward  by  rubber  or  glass  cyUnders. 

Puncture  thi'ough  the  rectum  should  be  rejected.  Pmictm-e  or 
incision  thi-ough  the  bladder,  in  cases  where  incision  thi'ough  the 
perinfeum  presents  too  much  danger,  should  be  considered.  A 
collection,  in  which  rupture  appears  imminent  could  be  thus 
evacuated  without  opening  the  peritouffium.  But  the  penetration 
of  urine  into  the  sac  and  its  possible  infection  by  the  cystitis  caused 
by  the  evacuation  of  the  altered  blood  constitutes  a  great  danger. 
The  para-rectal  or  para-sacral  incision  might  be  apphcable  in  some 
cases. 

3.  Total  hamatometra. — Atresia  of  the  cervix  uteri. — The  obliter- 
ation may  occur  at  the  external  orifice  or  at  the  internal  opening. 
In  the  latter  case  dilatation  of  the  cervix  is  commenced  by  succes- 
sive laminaria  tents  and  the  introduction  of  a  sound  is  attempted. 
If  this  fails,  or  if  there  is  obliteration  of  the  external  orifice, 
puncture  is  first  made  i,\"ith  a  trocar,  then  the  knife  or  scissors  is 
used  to  enlarge  the  opening.  After  repeated  irrigation  with  a  weak 
antiseptic  solution  tamponnemeut  of  the  uterine  cavity  ^ith  iodo- 
form gauze  is  used  to  maintain  a  shght  dilatation  for  several  days. 
"\^*hen  the  uterus  has  returned  to  its  normal  dimensions,  the  me- 
tritis that  is  the  consequence  of  the  primary  lesion  should  be 
treated  bv  curetting. 


Accidents  of  Retention  Consecutive  to  Genital  Atresias.        603 

4.  Lateral  hcEmatocolpus  and  lateral  hcematometra.  —  In  lateral 
bffimatocolpiis,  Schroeder,  in  order  to  avoid  the  occurrence  of  con- 
ception on  the  closed  side,  recommends  not  to  excisethe  septum  too 
extensively,  in  such  a  way  as  to  admit  the  penis.  Such  a  precaution 
appears  illusory;  to  me  it  seems  preferable  to  freely  excise  the 
septum  and  transform  the  double  vagina  into  a  single  canal. 


Fig.  357. — Lateral  haematocolpus  and  lateral  hsematometra. 
Schematic  figure  (A.  Martin). 

A  very  great  difficulty  exists,  in  treatment  as  well  as  diagnosis, 
when  the  blood  has  accumulated  in  a  rudimentary  cornu,  often  with 
an  elongated  pedicle,  forming  a  tumor  that  appears  independent  of 
the  principal  portion  of  the  uterus.  Incision  of  the  collection 
through  the  vagina  has  been  advised.  This  appears  more  dangerous 
than  laparotomy,  followed  by  extirpation  of  the  rudimentary  cornu 
and  of  the  corresponding  tube.  If  the  adhesions  render  extu-pation 
too  dangerous  the  sac  may  be  sutured  to  the  abdominal  wall  and  its 
obliteration  left  to  granulation.  Hysterectomy  may  also  be  indi- 
cated in  certain  cases  of  uterus  bicornis.  The  tumor  is  generally 
easily  pedunculized  at  the  cervix. 

5.  Hematosalpinx.  —  What  course  should  be  foUowed  when 
haematosalpinx  comphcates  the  gynatresias?  They  must  not  be 
neglected,  for  rupture  of  the  tube  has  often  caused  death.  Fuld 
has  collected  sixty-six  cases  of  gynatresia,  acquired  and  congenital, 
in  which  this  accident  has  been  reported,  and  in  forty-eight  cases 
it  was  followed  by  death.  Among  these,  thii'ty-nine  were  followed' 
with  operative  measures  and  nine  occurred  without  surgical  inter- 
ference. 


604        Accidents  of  Retention  Consecutive  to  Genital  Atresias. 

To  appreciate  the  operative  indications  it  is  necessary  to  know 
the  natural  evohition  of  the  tubal  collection  after  the  vaginal  or  the 
uterine  tumor  has  been  evacuated.  In  many  cases,  if  care  has 
been  taken  to  create  a  sufficiently  large  opening  for  the  flow  of 
blood,  and  to  maintain  it,  the  hsematosalpinx  is  evacuated  little  by 
httle  and  disappears.  But  there  are  also  many  cases  in  wliich  the 
tubal  tumor  has  undergone  no  change,  or  it  has  diminish'dd  and  re- 
appeared again  at  the  following  menstruation.  It  is  in  these  cases 
that  it  is  necessary  to  operate. 


Fig.  358 Lateral  haematometra  in  a  segment  of  a  double  uterus.    Schematic  figure 

(StaudeJ.  a b,  insertions  of  the  right  tube  and  round  ligament;  c,  os  iliacus;  d, 
symphysis  pubis;  f,  uterus:  g h,  insertions  of  the  left  tube  and  round  ligament;  i, 
umbilicus. 

Simple  evacuation  of  the  hsematosalpinx  by  punctui-e  has  been 
proposed,  but  although  less  formidable  in  appearance  it  is  really 
more  dangerous  than  extirpation.  Puncture  through  the  vaginal 
cul-de-sac  has  been  attended  with  success,  but  it  is  liable  to  wound 
the  intestines  and  the  bladder,  to  cause  effusion  of  blood  into  the 
peritonaeum  and  to  force  suppui-ation  of  the  sac.  Puncture  through 
the  abdominal  wall  is  liable  to  the  same  objection. 

There  is  .another  condition  in  which  salpingotomy  is  indicated. 
That  is  when,  before  or  after  an  operation  on  the  occluded  vagina 
or  uterus,  the  tubal  tumor  suddenly  gives  way,  'withoiit  an  external 
discharge  of  blood  in  proportion  to  its  diminution  of  volume.  There 
is  then  a  very  probable  haemorrhage  into  the  peritoneum.  The 
gi'ave  symptoms  of  internal  hfemorrhage  make  this  fact  certain  and 
demand  an  immediate  laparotomy. 


"v^Ui. 


Ai 


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